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43
![DHHS Form 400 "Application for Medicaid Family Planning Coverage" - South Carolina](https://data.templateroller.com/pdf_docs_html/2092/20925/2092546/dhhs-form-400-application-for-medicaid-family-planning-coverage-south-carolina.png "DHHS Form 400 "Application for Medicaid Family Planning Coverage" - South Carolina")
DHHS Form 400 "Application for Medicaid Family Planning Coverage" - South Carolina
Size: 263 KB
5 pages
![Form WKR009 "Annual Tefra Review Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178158/form-wkr009-annual-tefra-review-form-south-carolina.png "Form WKR009 "Annual Tefra Review Form" - South Carolina")
![DHHS Form 207 "Application for the Medically Indigent Assistance Program" - South Carolina](https://data.templateroller.com/pdf_docs_html/2322/23229/2322958/dhhs-form-207-application-for-the-medically-indigent-assistance-program-south-carolina.png "DHHS Form 207 "Application for the Medically Indigent Assistance Program" - South Carolina")
![Form WKR002 "Annual Review Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/1923/19233/1923333/form-wkr002-annual-review-form-south-carolina.png "Form WKR002 "Annual Review Form" - South Carolina")
![Form WKR001 "Annual Review Form - Aged, Blind, or Disabled Individuals (Abd)" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178162/form-wkr001-annual-review-form-aged-blind-or-disabled-individuals-abd-south-carolina.png "Form WKR001 "Annual Review Form - Aged, Blind, or Disabled Individuals (Abd)" - South Carolina")
![Form WKR007 "Review Form - Breast & Cervical Cancer Program" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178160/form-wkr007-review-form-breast-cervical-cancer-program-south-carolina.png "Form WKR007 "Review Form - Breast & Cervical Cancer Program" - South Carolina")
![Form WKR003 "Annual Review Form - People in a Nursing Home or Receiving Community Long Term Care Services in Your Home" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178163/form-wkr003-annual-review-form-people-in-a-nursing-home-or-receiving-community-long-term-care-services-in-your-home-south-carolina.png "Form WKR003 "Annual Review Form - People in a Nursing Home or Receiving Community Long Term Care Services in Your Home" - South Carolina")
![Form WKR008 "Family Planning Review Notice" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178156/form-wkr008-family-planning-review-notice-south-carolina.png "Form WKR008 "Family Planning Review Notice" - South Carolina")
![DHHS Form 1716 "Request for Medicaid Id Number - Infant" - South Carolina](https://data.templateroller.com/pdf_docs_html/2144/21448/2144846/dhhs-form-1716-request-for-medicaid-id-number-infant-south-carolina.png "DHHS Form 1716 "Request for Medicaid Id Number - Infant" - South Carolina")
![DHHS Form 3404 "Covid-19 Limited Benefit" - South Carolina](https://data.templateroller.com/pdf_docs_html/2323/23230/2323034/dhhs-form-3404-covid-19-limited-benefit-south-carolina.png "DHHS Form 3404 "Covid-19 Limited Benefit" - South Carolina")
![DHHS Form 3400 "Application for Medicaid and Affordable Health Coverage" - South Carolina](https://data.templateroller.com/pdf_docs_html/2049/20495/2049545/dhhs-form-3400-application-for-medicaid-and-affordable-health-coverage-south-carolina.png "DHHS Form 3400 "Application for Medicaid and Affordable Health Coverage" - South Carolina")
![DHHS Form 1282 "Authorization for Release of Information and Appointment of Authorized Representative for Medicaid Applications/Reviews and Appeals" - South Carolina](https://data.templateroller.com/pdf_docs_html/2092/20925/2092545/dhhs-form-1282-authorization-for-release-of-information-and-appointment-of-authorized-representative-for-medicaid-applications-reviews-and-appeals-south-carolina.png "DHHS Form 1282 "Authorization for Release of Information and Appointment of Authorized Representative for Medicaid Applications/Reviews and Appeals" - South Carolina")
![DHHS Form 3402 "Presumptive Eligibility Application" - South Carolina](https://data.templateroller.com/pdf_docs_html/2080/20800/2080066/dhhs-form-3402-presumptive-eligibility-application-south-carolina.png "DHHS Form 3402 "Presumptive Eligibility Application" - South Carolina")
![DHHS Form 1514 "Disclosure of Ownership and Control Interest Statement" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21777/2177749/dhhs-form-1514-disclosure-of-ownership-and-control-interest-statement-south-carolina.png "DHHS Form 1514 "Disclosure of Ownership and Control Interest Statement" - South Carolina")
![DHHS Form 913-A "Application Addendum - Breast & Cervical Cancer Program" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178169/dhhs-form-913-a-application-addendum-breast-cervical-cancer-program-south-carolina.png "DHHS Form 913-A "Application Addendum - Breast & Cervical Cancer Program" - South Carolina")
![DHHS Form 3400-A "Additional Information for Select Medicaid Programs" - South Carolina](https://data.templateroller.com/pdf_docs_html/2178/21781/2178166/dhhs-form-3400-a-additional-information-for-select-medicaid-programs-south-carolina.png "DHHS Form 3400-A "Additional Information for Select Medicaid Programs" - South Carolina")
![DHHS Form 3400-B "Additional Information for Nursing Home and in-Home Care" - South Carolina](https://data.templateroller.com/pdf_docs_html/1923/19233/1923334/dhhs-form-3400-b-additional-information-for-nursing-home-and-in-home-care-south-carolina.png "DHHS Form 3400-B "Additional Information for Nursing Home and in-Home Care" - South Carolina")
![DHHS Form 3400-E "Application Addendum - Tuberculosis (Tb) Referral" - South Carolina](https://data.templateroller.com/pdf_docs_html/2092/20925/2092548/dhhs-form-3400-e-application-addendum-tuberculosis-tb-referral-south-carolina.png "DHHS Form 3400-E "Application Addendum - Tuberculosis (Tb) Referral" - South Carolina")
![DHHS Formulario 400 DHEC "Solicitud De Medicaid Planificacion Familiar" - South Carolina (Spanish)](https://data.templateroller.com/pdf_docs_html/1965/19656/1965614/dhhs-formulario-400-dhec-solicitud-de-medicaid-planificacion-familiar-south-carolina-spanish.png "DHHS Formulario 400 DHEC "Solicitud De Medicaid Planificacion Familiar" - South Carolina (Spanish)")
![DHHS Form 400 DHEC "Application for Medicaidfamily Planning Coverage" - South Carolina](https://data.templateroller.com/pdf_docs_html/2037/20379/2037930/dhhs-form-400-application-for-medicaidfamily-planning-coverage-south-carolina.png "DHHS Form 400 DHEC "Application for Medicaidfamily Planning Coverage" - South Carolina")
!["Electronic Funds Transfer (Eft) Authorization Agreement" - South Carolina](https://data.templateroller.com/pdf_docs_html/2186/21863/2186302/electronic-funds-transfer-eft-authorization-agreement-south-carolina.png ""Electronic Funds Transfer (Eft) Authorization Agreement" - South Carolina")
!["South Carolina Medicaid Program Annual Review Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/2037/20379/2037928/south-carolina-medicaid-program-annual-review-form-south-carolina.png ""South Carolina Medicaid Program Annual Review Form" - South Carolina")
!["Hardship Waiver Exception Request" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21777/2177748/hardship-waiver-exception-request-south-carolina.png ""Hardship Waiver Exception Request" - South Carolina")
!["Request for Rehabilitative Behavioral Health Services Limit Exception" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21774/2177423/request-for-rehabilitative-behavioral-health-services-limit-exception-south-carolina.png ""Request for Rehabilitative Behavioral Health Services Limit Exception" - South Carolina")
!["Authorization to Disclose Health Information" - South Carolina](https://data.templateroller.com/pdf_docs_html/1923/19233/1923338/authorization-to-disclose-health-information-south-carolina.png ""Authorization to Disclose Health Information" - South Carolina")
!["Rehabilitative Behavioral Health Services (Rbhs) Referral Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21774/2177421/rehabilitative-behavioral-health-services-rbhs-referral-form-south-carolina.png ""Rehabilitative Behavioral Health Services (Rbhs) Referral Form" - South Carolina")
!["Rehabilitative Behavioral Health Services (Rbhs) Parent/Caregiver/Guardian Agreement to Participate in Community Support Services" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21774/2177420/rehabilitative-behavioral-health-services-rbhs-parent-caregiver-guardian-agreement-to-participate-in-community-support-services-south-carolina.png ""Rehabilitative Behavioral Health Services (Rbhs) Parent/Caregiver/Guardian Agreement to Participate in Community Support Services" - South Carolina")
!["Servicios De Salud Conductual Y Rehabilitacion (Rbhs) Acuerdo Del Padre/La Madre/El Cuidador/El Tutor Legal Para Participar En Servicios De Apoyo Comunitario" - South Carolina (Spanish)](https://data.templateroller.com/pdf_docs_html/2177/21774/2177422/servicios-de-salud-conductual-y-rehabilitacion-rbhs-acuerdo-del-padre-la-madre-el-cuidador-el-tutor-legal-para-participar-en-servicios-de-apoyo-comunitario-south-carolina-spanish.png ""Servicios De Salud Conductual Y Rehabilitacion (Rbhs) Acuerdo Del Padre/La Madre/El Cuidador/El Tutor Legal Para Participar En Servicios De Apoyo Comunitario" - South Carolina (Spanish)")
!["Accreditation for Rehabilitative Behavioral Health Services" - South Carolina](https://data.templateroller.com/pdf_docs_html/2186/21860/2186077/accreditation-for-rehabilitative-behavioral-health-services-south-carolina.png ""Accreditation for Rehabilitative Behavioral Health Services" - South Carolina")
!["Medicaid Credit Balance Report - Claim Detail" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21778/2177871/medicaid-credit-balance-report-claim-detail-south-carolina.png ""Medicaid Credit Balance Report - Claim Detail" - South Carolina")
!["Preceptor/Protocol Agreement Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21777/2177752/preceptor-protocol-agreement-form-south-carolina.png ""Preceptor/Protocol Agreement Form" - South Carolina")
!["Civil Rights Discrimination Complaint" - South Carolina](https://data.templateroller.com/pdf_docs_html/2092/20925/2092549/civil-rights-discrimination-complaint-south-carolina.png ""Civil Rights Discrimination Complaint" - South Carolina")
!["Sc Trading Partner Agreement/Remittance Advice Enrollment" - South Carolina](https://data.templateroller.com/pdf_docs_html/2172/21721/2172133/sc-trading-partner-agreement-remittance-advice-enrollment-south-carolina.png ""Sc Trading Partner Agreement/Remittance Advice Enrollment" - South Carolina")
!["Sc Trading Partner Agreement Enrollment" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21777/2177751/sc-trading-partner-agreement-enrollment-south-carolina.png ""Sc Trading Partner Agreement Enrollment" - South Carolina")
!["Trading Partner Agreement Enrollment for Vendors and Clearinghouses" - South Carolina](https://data.templateroller.com/pdf_docs_html/2186/21863/2186301/trading-partner-agreement-enrollment-for-vendors-and-clearinghouses-south-carolina.png ""Trading Partner Agreement Enrollment for Vendors and Clearinghouses" - South Carolina")
!["Medicaid Credit Balance Report - Certification Page" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21778/2177893/medicaid-credit-balance-report-certification-page-south-carolina.png ""Medicaid Credit Balance Report - Certification Page" - South Carolina")
!["Drug-Free Workplace Act Certification Statement" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21779/2177948/drug-free-workplace-act-certification-statement-south-carolina.png ""Drug-Free Workplace Act Certification Statement" - South Carolina")
!["Minority Business Form" - South Carolina](https://data.templateroller.com/pdf_docs_html/2177/21779/2177951/minority-business-form-south-carolina.png ""Minority Business Form" - South Carolina")