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GAFC
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Is the person receiving care eligible for Medicaid?
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Not Sure
How are you related to the person you're caring for?
*
Daughter
Son
Spouse
Mother
Father
Grandchild
Sister
Brother
Other
Which activities does the person receiving care need help with?*(check all that apply)
Bathing
Dressing
Getting in and out of bed or on and off chairs
Using the bathroom
Eating
Other
Medicaid? person Referrer
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