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Document Number: DVR-18045-E
Description: This form is to be completed by DVR Service Providers to report on benefits consultation period services authorized by DVR.
Comments: Form is protected from modification and enabled for form fill (includes tabbed fields for form completion).
Content Contact: DVR Forms
DVR-18045-E (Electronic Version - Word/66 KB)
DVR-18045-E (Electronic Version - pdf/86 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.