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RESET FIELDS PA 1723 Instructions for Completion The top of Page 1 should be completed by the MPP Case Manager or Authorized Agent such as the BETP contractor (MPP, SPOC, Supported Work, etc.), who is initiating the nee
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Document Date: 2012-05-09 09:56:04


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Facility

LABORATORY TESTS / /

Holiday

Commonwealth Day / /

MedicalCondition

HIV / drug abuse / HIV/AIDS / /

Organization

Pennsylvania Department of Public Welfare Authorization for Release of Information Date County County/Record Number MPP / /

Position

General / Smith CAO / MPP Case Manager / CAO Worker / Caseworker / BETP contractor / WCA Contractor / CAO / /

ProvinceOrState

Pennsylvania / Information Date County County / /

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