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Michigan Department of Community Health Document Number MEDICAL TRANSPORTATION STATEMENT Only ONE medical provider and ONE transporter per form. See Page 2 for Instructions Copy Distribution PA 431 and Non-Discrimination Information. SECTION I - DHS Specialist Completes DHS Specialist Name Authorized Rate Standard Special Patient/ Beneficiary Name DHS Case No. CO MA-TOA Level of Care Code Beneficiary ID No....
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mi dhs msa 4674
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