ࡱ                >  	               n          p          m    '`	               A   bjbjLULU                  	 ;P  .? .? =                                                                                                                                      8   R  l     l         H    6  h                          y    ]    y     UG     WG      WG      WG      WG      WG      WG  $   I  h  $L     {G  Q                                               y      y                  {G                                             G     =      =      =        X                           UG              =                                                            UG              =              =                                                                          =            *     ?]R                X   =              E  l  G  0   H      =      L      e    L      =                                                                      =     L                    Q  (  	  "   +     =      C     W  ^                                   	      	      	      {G      {G                                        X                                   	      	      	      H                                                        $                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       M e d i c a i d   P r o b l e m   R e p o r t   S h e e t  D a t e   o f   R e p o r t :    F O R M T E X T             C o n s u m e r   N a m e :    F O R M T E X T            M e d i c a i d   N u m b e r :    F O R M T E X T            D a t e   o f   B i r t h :    F O R M T E X T             A d d r e s s :    F O R M T E X T            C o u n t y :    F O R M T E X T             N a m e   o f   C o n t a c t   P e r s o n :    F O R M T E X T             R e l a t i o n s h i p   t o   C o n s u m e r :    F O R M T E X T            C o n t a c t   P e r s o n  s   T e l e p h o n e :    F O R M T E X T            E m a i l :    F O R M T E X T             N a m e   o f   M e d i c a i d   H M O :    F O R M T E X T            M e d i c a i d   H M O   N u m b e r :    F O R M T E X T            D a t e   o f   E n r o l l m e n t :    F O R M T E X T             D o e s   C o n s u m e r   h a v e   M e d i c a r e ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o  P r i v a t e   H e a l t h   I n s u r a n c e ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o  N a m e   o f   P r i v a t e   I n s u r a n c e   C o m p a n y :    F O R M T E X T             B r i e f   D e s c r i p t i o n   o f   C o n s u m e r  s   D i a g n o s i s / H e a l t h   I s s u e s :    F O R M T E X T             B r i e f   D e s c r i p t i o n   o f   P r o b l e m :    F O R M T E X T             M e d i c a t i o n   c o - p a y   p r o b l e m ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o  I f   y e s ,   n a m e   o f   m e d i c a t i o n ( s ) :    F O R M T E X T             C o v e r e d   u n d e r   M e d i c a r e   P a r t   D ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o  M e d i c a r e   P a r t   D   d r u g   p l a n :    F O R M T E X T             C o v e r e d   U n d e r   P r i v a t e   I n s u r a n c e ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o  N a m e   o f   I n s u r a n c e   C o m p a n y :    F O R M T E X T             B r i e f   D e s c r i p t i o n   o f   t h e   M e d i c a t i o n   C o - p a y   p r o b l e m :    F O R M T E X T             I f   p r o b l e m   i s   w i t h      "  .  :  <  Z  \  p  r  t  ~                  ǹ|rcSG1S    +jv   h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  j    h3  CJ OJ QJ UaJ hr# h CJ OJ QJ aJ  hV= OJ QJ ^J  hig| hig| OJ QJ ^J  %j    h3  5OJ QJ UmH nH u&j    h3  h 5OJ QJ U h3  5OJ QJ j    h3  5OJ QJ U hy hig| 5OJ QJ hV= CJ OJ QJ ^J aJ  hl CJ OJ QJ ^J aJ   h h CJ OJ QJ ^J aJ    <        	  T	  V	                                                                          C                          kd  $$If   l             (F !, &                                  y                
t  0                              ,6                                        4   4 
l a  yt3 	  $If   gd    $a$gdV=    $^`a$gd3     $a$gdV=     z@  A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              	  	  	  	  ,	  .	  B	  D	  F	  P	  R	  V	  f	  h	  |	  ~	  	  	  	  	  	  ˼ڰڼڰڼuڰ_uS                           hn CJ OJ QJ aJ  +j{  h3  h CJ OJ QJ UaJ hr# hV= CJ OJ QJ aJ  +jx  h3  h CJ OJ QJ UaJ +j  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  hr# h CJ OJ QJ aJ  hr# h^ CJ OJ QJ aJ  j    h3  CJ OJ QJ UaJ *j    h3  CJ OJ QJ UaJ mH nH uV	  	  	  	  
  
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                          v                                                m            m                                                                                          	  $If   gd    kde  $$If   l             g0 !,                  y                
t  0                              ,6                            4   4 
l a  yt3 	  $If   gd  	  	  	  	  	  	  	  	  	  	  

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        4  6  8  L  N  P  Z  \  ^  ٴ٨ٴ٨|ٴm^٨H^+j  h3  h CJ OJ QJ UaJ hr# h^ CJ OJ QJ aJ  hr# h CJ OJ QJ aJ  +j*  h3  h CJ OJ QJ UaJ +j  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  hr# h CJ OJ QJ aJ  *j    h3  CJ OJ QJ UaJ mH nH u j    h3  CJ OJ QJ UaJ +jB  h3  h CJ OJ QJ UaJ  
    ^      n            e            e            e                                                                                                                                              	  $If   gd    kd  $$If   l             F !, &                                  y                
t  0                              ,6                                        4   4 
l a  yt3  ^                                6  8  :  V  X  Z  b  d                  տՓnXՄ                 +jx  h3  h CJ OJ QJ UaJ +j  h3  h CJ OJ QJ UaJ hr# h^ CJ OJ QJ aJ  +j  h3  h CJ OJ QJ UaJ *j    h3  CJ OJ QJ UaJ mH nH u +j  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  j    h3  CJ OJ QJ UaJ hr# h CJ OJ QJ aJ         |  l            c            Z            c                                                                                                                        	  $If   gd^ 	  $If   gd    kd  $$If   l             pF !, &                                  y                
t  0                              ,6                                        4   4 
l a  yt3                
    T  V  j  l  n  x  z  ~                    R  T  h  ͷͨ͒|٨mW|٨m                              +j
  h3  h CJ OJ QJ UaJ hr# h CJ OJ QJ aJ  *j    h3  CJ OJ QJ UaJ mH nH u +j	  h3  h CJ OJ QJ UaJ hr# h^ CJ OJ QJ aJ  +j`	  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  j    h3  CJ OJ QJ UaJ +j  h3  h CJ OJ QJ UaJ  |  ~                x                                                                                                                                                                                                                      	  $If   gd  }  kdJ
  $$If   l             0 , &                 b                
t  0                              ,6                            4   4 
l a  yt3      z  |                                        l  kd  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3 	  $If   gd  l  kd%  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3  h  j  l  v  x                          @  B  V  X  Z  d  f  j          ٴ٨٨٨|٨m٨Wm٨                              +j)  h3  h CJ OJ QJ UaJ hr# h CJ OJ QJ aJ  +j  h3  h CJ OJ QJ UaJ +jA  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  hr# h^ CJ OJ QJ aJ  *j    h3  CJ OJ QJ UaJ mH nH u j    h3  CJ OJ QJ UaJ +jx  h3  h CJ OJ QJ UaJ  |    h  j    V                          v            m            m                                                                                                                                             	  $If   gd    kd  $$If   l             0 ,                                  
t  0                              ,6                            4   4 
l a  yt3 	  $If   gd                      &  .  0  D  F  H  R  T            ͷͨ̓m٨aQa;    +j  hn h CJ OJ QJ UaJ j    hn CJ OJ QJ UaJ hn CJ OJ QJ aJ  *j    h3  CJ OJ QJ UaJ mH nH u +j  h3  h CJ OJ QJ UaJ hr# h CJ OJ QJ aJ  hr# h^ CJ OJ QJ aJ  +j|  h3  h CJ OJ QJ UaJ h3  CJ OJ QJ aJ  j    h3  CJ OJ QJ UaJ +j  h3  h CJ OJ QJ UaJ  V  X    H              v            v                                                                                                                                                                                                 	  $If   gd    kdf  $$If   l             0 ,                                  
t  0                              ,6                            4   4 
l a  yt3                     "  6  8  :  D  F  J                      :  r:  t:  :  :  :  :  :  :  ﾃmkU +ja  hn h CJ OJ QJ UaJ U+j  hn h CJ OJ QJ UaJ hr# h CJ OJ QJ aJ  *j    hn CJ OJ QJ UaJ mH nH u +j  hn h CJ OJ QJ UaJ hr# h^ CJ OJ QJ aJ  +jC  hn h CJ OJ QJ UaJ hn CJ OJ QJ aJ  j    hn CJ OJ QJ UaJ  !H  J                v                                                                                                                                                                                                                  	  $If   gd    kd/  $$If   l             0 ,                                  
t  0                              ,6                            4   4 
l a  yt3      :  :                                        l  kd  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3 	  $If   gd  l  kd  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3  t h e   m e d i c a t i o n   c o - p a y ,   n a m e   a n d   p h o n e   n u m b e r   o f   p h a r m a c y :    F O R M T E X T             H a v e   y o u   c o n t a c t e d   a   M e d i c a i d   H M O   C a r e   M a n a g e r ?      F O R M C H E C K B O X     Y e s      F O R M C H E C K B O X     N o         I f   y e s ,   n a m e   o f   C a r e   m a n a g e r   ( i f   k n o w n )   a n d   b r i e f   d e s c r i p t i o n   o f   w h a t   h a p p e n e d :    F O R M T E X T             I   g i v e   p e r m i s s i o n   f o r   t h i s   i n f o r m a t i o n   t o   b e   f o r w a r d e d   t o   T h e   A r c   o f   N e w   J e r s e y ,   a n d   a l s o   g i v e   p e r m i s s i o n   f o r   i t   t o   b e   f o r w a r d e d   t o   t h e   N J   D i v i s i o n   o f   M e d i c a l   A s s i s t a n c e   a n d   H e a l t h   S e r v i c e s   ( N J   M e d i c a i d ) .  * S i g n a t u r e :    F O R M T E X T            D a t e :    F O R M T E X T                P l e a s e   e m a i l   t h i s   c o m p l e t e d   f o r m   t o   B e v e r l y   R o b e r t s   a t      H Y P E R L I N K   " m a i l t o : b r o b e r t s @ a r c n j . o r g "     b r o b e r t s @ a r c n j . o r g    o r   t o   H e l e n   R i v e r a   a t      H Y P E R L I N K   " m a i l t o : h r i v e r a @ a r c n j . o r g "     h r i v e r a @ a r c n j . o r g  .     T h e   f o r m   m a y   a l s o   b e   f a x e d   t o   ( 7 3 2 )   2 1 4 - 1 8 3 4 .     W e   w i l l   g e t   b a c k   t o   y o u   a s   s o o n   a s   p o s s i b l e .               * E l e c t r o n i c   S i g n a t u r e   a c c e p t e d :     T y p e d   s i g n a t u r e   w i t h   d a t e   i n d i c a t e s   e l e c t r o n i c   v e r i f i c a t i o n   o f   t h e   i n f o r m a t i o n   p r o v i d e d . 	 	                     R e v i s e d   0 8 / 2 0 1 1                                                                   :  :  :  :  :  :  ;  ;  ;  &;  (;  D;  F;  H;  T;  ;  ;  ;  ;  <  
<  <  <  <  <  =  =  =  ٳٝهq`RF hn CJ OJ QJ aJ  h CJ OJ QJ ^J aJ   hr# hr# CJ OJ QJ ^J aJ  *j    h3 CJ OJ QJ UaJ mH nH u +j  hn h3 CJ OJ QJ UaJ +j  hn h3 CJ OJ QJ UaJ +j*  hn h3 CJ OJ QJ UaJ j    h3 CJ OJ QJ UaJ h3 CJ OJ QJ aJ  hex CJ OJ QJ aJ  hr# h3 CJ OJ QJ aJ :  <  <  =  =  &>                                      ~            p                                                                                                                                                      $$If   a$gd K$ 
  $If   gdn K$ l  kd  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3 	  $If   gd  =  =  =  =  =  =  =  =   >  >  >  >  ">  $>  &>  (>  ,>  .>  >  >  >  >  >  sgVgBV                  &j  hr# hi. 5OJ QJ U  j    hr# hi. 5OJ QJ U hr# hi. 5OJ QJ hr# CJ OJ QJ aJ  hr# h CJ OJ QJ aJ  %h) hn B*	CJ OJ QJ aJ ph   +jU  hn h CJ OJ QJ UaJ *j    hn CJ OJ QJ UaJ mH nH u +j  hn h CJ OJ QJ UaJ hn CJ OJ QJ aJ  j    hn CJ OJ QJ UaJ  &>  (>  *>  ,>  .>                          /            *                           gd@=  l  kdv  $$If   l              ,                 
t  0                              ,6                4   4 
l a  yt3 	  $If   gd Z  kd  $If   K$L$l m0   + <                 L                
t  +6                            4   4 
l a  yt3  >  ?  ?  ?  $?  D?  F?  ?  ?  ?  ?  ?  v@  z@  |@  @  @  @  @  @  @  @  @  A  A  A  A  A  A  A  A  Դԥ}qbqSO    h  h*{ h CJ OJ QJ aJ  h h CJ OJ QJ aJ  h CJ OJ QJ aJ  h>G h 6CJ OJ QJ aJ h CJ OJ QJ aJ  h	  j    h	 Uhr# hi. CJ OJ QJ aJ  &j  hr# hi. 5OJ QJ U hr# hr# 5OJ QJ hr# hi. 5OJ QJ  j    hr# hi. 5OJ QJ U hr# hi. 0J 5OJ QJ  .>  x@  z@  ~@  @  @  @  @  @  @  @  A  A  A  A                                                                                                                                                                                                                                                                                                                                                                                                                                gd*{       gd@=  A  A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           hr# hi. CJ OJ QJ aJ 9 
0&P 1h:p@= / =!"#h$h%  hh                                                                                                                                                                                                                                                                                                                                                                                                                                                                     v   D                                                                             M / d / y y                      D                                                                      T e x t 1        F I R S T   C A P I T A L                   t   D                                                                      T e x t 2                              D                                                                     T e x t 3        M / d / y y y y                   } $$If     !v h5 55-
#v #v#v-
:V l (
t  ,6  5 &55yyt3 t   D                                                                      T e x t 4                           v   D                                                                     T e x t 2 3                           g $$If     !v h5 D"5-
#v D"#v-
:V l g
t  ,6  5 5yyt3 t   D                                                                     T e x t 5                           t   D                                                                     T e x t 6                           t   D                                                                     T e x t 7                           t   D                                                                     T e x t 8                           y $$If     !v h5 55-
#v #v#v-
:V l 
t  ,6  5 &55yyt3 t   D                                                                     T e x t 9                           v   D                                                                     T e x t 1 0                              D                                                                     T e x t 1 1        M / d / y y                   } $$If     !v h5 55-
#v #v#v-
:V l p
t  ,6  5 &55yyt3 t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         v   D                                                                     T e x t 1 2                           c $$If     !v h5 5#v #v:V l 
t  ,6  5 &5byt3 v   D                                                                     T e x t 1 3                           Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3 v   D                                                                     T e x t 1 4                           Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3 t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         v   D                                                                     T e x t 1 5                           g $$If     !v h5 5W#v #vW:V l 
t  ,6  5 5yt3 t   D                                                               e     C h e c k 7                         t   D                                                               e     C h e c k 8                         v   D                                                                     T e x t 1 6                           g $$If     !v h5 5W#v #vW:V l 
t  ,6  5 5yt3 t   D                                                               e     C h e c k 9                         v   D                                                               e     C h e c k 1 0                         v   D                                                                     T e x t 1 7                           g $$If     !v h5 5W#v #vW:V l 
t  ,6  5 5yt3 v   D                                                                     T e x t 1 8                           Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3 v   D                                                                     T e x t 1 9                           Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3 v   D                                                               e     C h e c k 1 1                         v   D                                                               e     C h e c k 1 2                         v   D                                                                     T e x t 2 0                           Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3 v   D                                                                     T e x t 2 1                              D                                                                     T e x t 2 2        M / d / y y                    $If   K$L$l !v h5 5#v #v:V l m
t  0                                          +6  5 <5Lyt3 Q $$If     !v h5 q,#v q,:V l 
t  ,6  5 yt3    D                                                                y  K         b r o b e r t s @ a r c n j . o r g   y  KL   m a i l t o : b r o b e r t s @ a r c n j . o r g   yX;H,]ą'c         D                                                                y  K         h r i v e r a @ a r c n j . o r g   y  KJ   m a i l t o : h r i v e r a @ a r c n j . o r g   yX;H,]ą'c                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  @  @ @          N o r m a l       CJ _HaJ mH	sH	tH	                  D A@ D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
l 4   a      ( k  (           N o   L i s t          H    H   S    B a l l o o n   T e x t      CJ OJ QJ ^J aJ j @ j      
 T a b l e   G r i d   7 :V 0                                   4 @ 4   @=    H e a d e r      !   4  @ "4   @=    F o o t e r      !   6 U@ 16   i.   	 H y p e r l i n k    >*B*ph           P          A   B   d                         <  k              E            =  >          +  ,  v          M  N                    <  =  ?  @  B  C  E  F  H  I            0                        0                        0                        0                      0                      0                      0                      0                      0                     0                      0                      0                      0                     0                     0                     0                      0                      0                      0                      0                      0                      0                     0                     0                      0                      0                      0                      0                      0                      0                     0                      0                      0                     0                      0                      0                     0                      0                      0                      0                      0                      0                     0                      0                      0                      0                      0                      0                      0                      0                        0                                           @   0                    0 0                   @   0                    0 0                   @   0                    0 0                   @   0                    0 0                   @  0                   @   0                    0 0                 '    A   B        <  k              E          =  >        +  v      M               0 0         /          0 0         .          0 0               P 00                00                  00                  0 0                  00                 00                  00                  0 0                  00                  00                  00                00               f  0 0               fn 00               f  00            	   0 0 0               |  0 0         	          0 0               n 0 0                   0 0                 n 00                   00                   0 0                 n 0"0            #    00                 @   0                 @   0                  00                @   0                                                    	                                   	  f
  ^    h      :  =  >  A  A  	                           !   #   %   '      V	  
    |    |  V  H    :  &>  .>  A  
                              "   $   &      A     -   9   ?   P   \   b   t                                           (  4  :  W  c  i  q  }                        ,  1  A  _  o  t              	  )  5  ;  Y  i  n  ~                  #  )  M  ]  b  r              9  E  K  ~                          N  w            FFFFFFFFFFFFFG G G G FFFG G FG G FG G FFFG G FFFXX  8                         @                           0    (    	                    
          B    
        S              	   ?          #    T e x t 1  T e x t 2  T e x t 3  T e x t 4  T e x t 2 3  T e x t 5  T e x t 6  T e x t 7  T e x t 8  T e x t 9  T e x t 1 0  T e x t 1 1  C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  T e x t 1 2  T e x t 1 3  T e x t 1 4  C h e c k 5  C h e c k 6  T e x t 1 5  C h e c k 7  C h e c k 8  T e x t 1 6  C h e c k 9  C h e c k 1 0  T e x t 1 7  T e x t 1 8  T e x t 1 9  C h e c k 1 1  C h e c k 1 2  T e x t 2 0  T e x t 2 1  T e x t 2 2 P   t               )  X  r          2  `  u      *  Z  o          N  c      :                                          	   
                                                                      !   "   c                 ;  j          -  B  p      
  <  j          *  ^  s      L                  ]9    ^9  $,;               J                >      *urn:schemas-microsoft-com:office:smarttags
PersonName   <                  =  =  ?  ?  @  @  B  C  E  F  H  I                        =  =  ?  ?  @  @  B  C  E  F  H  I                        -   @   P   c   t                             (  ;  W  j  q                  -  1  B  _  p  t          
  )  <  Y  j  n                  *  M  ^  b  s          9  L  N  N  c  p  ~                                                ;  ;  <  =  =  ?  ?  @  @  B  C  E  F  H                                                                                                                    =  =  ?  ?  @  @  B  C  E  F  H  I                     3            
               
  (  jA  xH  P  BS  ,[  e  (z  z  U}  & Y. 13 U jV \ w w     {/ 0 A F F .H J V p  [h i Rk Gm Dp w {    j  "/ )4 4 @ Q ` v   ; 00 M5 8 %= = m 2t    <K O ^ y (  " J X ,] h l t v W r( ) J0 2 OL d n u Tw   \	 	 	 6 	 %	 *	 3<	 ?	 G	 X	 p	 |	 
 
 
 
  
 ?
 G
 KO
 ]
 q
 D
 3 {4 %8 A N ^d l 2t ~w Yy u  P  {+ 8 ? aA C D H M P qS "W 9b wc h j 
 9 : F f m 6q q} s  5 _   50 7 ; = V Z 5_ o 
  u &C S c { D L  . .  A N F] ^ a c A  ,  D bM Y ac h j k ]t {   K  -5 6 E7 : uB CR K\ b g Eu "|   V {  * - 8 =B J vT i Sl l p    /& - E0 9 K a[ ^ Jc gs ] i & ( . '2 > N X |  :( ; QC 4J \ 8 5 > ? C  Z% dk q mt )u @| H
 1% b( QJ U Y  n  B   q g K+ r3 E; E Vf cn n o   n @ D S iX wf h p s x >z  . I \S d gu  ,  . 2, c/ e9 
A H ]h   g / qB I T W 7o Uw  n . - O jm o t }       -  &2  3  W  \  ! ! ! Z+! --! 6! AC! fT! X! Z! ;o! " \" e" e4" 7" 9" c" ~" # -# -# 3# 5# 07# ,<# 2=# H# !q# t# ix# $ {$ x
$ 
$ $ %$ b$ $ -$ {1$ 3$ ;$ F$ J$ R$ Z\$ b$ >l$ -z$ /% l% $% +% o7% $8% Y8% =>% @j% gx% =	& '& *& B& 5Y& m& z& |& l' 9'  ' 3$' /8' kG' _' f' ( ( !( z'( g>( E( O( H\( Xl( Dq( ) ) &
)  ) P0) 9) :) iR) g) Xs) 7w) ~) * >* FL* M* %Z* [* a]* Jf* lg* l* r* vu* 0|* + + + + %+ + ,+ .+ <+ _+ f+ jq+ u+ 
, M, "V, \, f, i, i, Uo, x, K, f- - - - 98- =- F- ]-  b- mr- H. S. 7. i. i. / 0/ 1/ 4/ 7/ K/ CS/ X/ ~Z/ `\/ ~]/ i/ n/ tq/ cs/ (x/ {/ / 0 /0 0 	O0 c0 1 %1 1  1 !1 &1 01 21 G81 o@1 B1 D1 R1 j1 ~1 Z	2 	2 2 $2 502 &12 ?2 C2 P2 ]2 ]2 f2 e2 3 33 3 "3 '3 B3 sL3 N3 eU3 V3 g3 1{3 4 4 4  4 >4 C4 Y4 Z4 u4 }4 5 5 85 D5 J5 _5 j5 p5 z5 x|5 6 n6 $,6 .6 46 );6 >6 \Y6 b6 h6  7 /7 I7 Y07 B7 ]7 he7 wm7 v7 8 8 d8 P)8 <J8 J8 d8 Xj8 3k8 r8 w8 w8 9 G9 ;9 p9 19 249 =9 .C9 F9 P9 yZ9 [9 k^9 p9 7: L: \%: 1: <: sg: A; /; C$; `0; G9; :; }U; b; h; {; 2< 3< I< e< 4< 5< ;< \< t< B
= = y= = 6= 8= >= 	C= _= \b= d= t= z= *> > 2.> => F> DK> S> Z> [g> Oz> M ? \? -? Q? V? m? n? O@ Z
@ 	@ $@ uQ@ [@ 1_@ A 2A 4A /:A ?A CA 
eA 0rA tA xA 	B B&B .B 6B jJB erB rB ?~B C C  C 7C f;C AWC 3YC ZC mC xC 1D D $D GD D  #D t$D 3D ^D fD sD xD 1|D CE }E E [!E ("E `0E AE IE OE UE XE \E IF (F sEF qFF JF NF FVF 2pF #vF G 
G )G 2G 7G >G L@G FG HG 8[G aG zcG jG G fH H CH !-H 3H ;H =H z@H ]H ^H YbH I I 1I @I FI SI oI WrI wxI J J 7J BJ CJ KJ eJ K 8K 9K TAK <[K K L nL L h*L ),L 2L ;L 3`L cL phL gpL ^vL vL yL M )M 4M @:M +BM KM TM ]M :zM F~M }~M N 'N gN !N "N */N 1N \N N^N eN oN }N ~N O 1O 9O =O NO bXO cO cO {O P }P )P AP 2P ->P @KP ZP eP >nP sP GP 9Q RQ R pR R b0R 18R 6=R (UR rUR bWR XR XR bR kR vR zR S S d4S [S T T T =T ?T DT GT mKT TT rT yT }T U 6U 49U NPU TU WU iU zvU {U 
V V V j+V /V 6:V E:V DV HV NV QV UV VV xV ^W VW HW 0W 3W )=W NW SW tW X BX &X SX tX 	Y Y Y 3WY _Y aY kbY lY nY pY Z V1Z 5DZ QZ %YZ UvZ  [ .[ 3[ L[ )z[ @	\ >\ $\ r\ %\ %2\ 2\ 6\ ^A\ N\ UR\ +Z\ h\ q\ Jw\ ] ] ] ] ] 6] o@] \H] I] SL] ~M] 9]] h] m] Wq] r] }y] (^ 9^ 5^ !^ T&^ (^ Q,^ V1^ 4D^ x_^ wm^ )u^ $_ :_ =_ >_ B_ {D_ O_ >p_ p_ ds_ t_ "` l` "` $` <` {>` aI` Q` S` Z` m` sn` =a xa 'a a 0a ;a Aa Ma Oa ZPa Wa v]a aa ga pa txa &b b Jb oQb Yb [b rb # c ic c !c wc )c "c #c 6Jc Nc !Tc <^c `c d d d \d d d *d 3d sTd Wd Wd ]d ^d bd Mud }d ~e >e e p"e *e W.e Z8e W=e Oe Qe g\e e %f f Gf Of &Yf k^f mf {f S
g g 8(g 6g 8g Bg Og 6`g h h 	h 94h 8h 8h 9h K>h REh Jh Jh Vh fh =i 0:i ii j j j j 
j j %j t/j 4j }Aj gEj Qj Rj n]j ej gj mj pj !k 1k Pk vk )l l hl =*l 3l 5l Gl iRl %Vl Zl bl C|l m 	m m m  m *m A=m =Xm Ygm om |m  n n nn $n $n Vn [n )tn xn ~n ,o cAo MBo Yo bo ho p|o p (p K)p |5p Rp \p ep qjp pp 
q $<q =Aq Sq .Yq eq kq mq uq ~q  r &r r !r &r r.r r0r 9r <<r =r 2>r '?r |Ir zMr tir ?mr ^sr wr s .s +s 5s {7s 7s 9s >s Fs Rs Ts qus ws qt &'t G1t Et Ot su q)u 1u 4u Uu [u 
v v v `v v (v .v Cv Dv ,\v cv kv w 
w w Mw +w =w Aw Jw Ow Pw Yw ew iw t}w x x !x "x 0-x 0x Tx [x cx cx Bex gx gx qux wx -0y Ry /sy z z 2z Fz Uz Vz ]z sz :uz ~~z { { *{ *{ ,2{ 8{ U={ G{ W{ [{ Ad{ 9l{ w{  | | :)| =| %H| (J| R| S| ig| ?p| iq| } j} !} /} 2=} >} C} 2H} I} S} m} 6{}  ~ `~ ~ 4~ 6~ C:~ M~ eR~ S~ i~  M f+ x+ - 2 @ ^ Od 4f g l  #   ' V= @ C ?E b i t  I 6 J `d r 2    q: V Y _ g m   U$ i9 6\ s  " ,( X6 ; > WG P <T vW Z i Kk %r ex s| | ( 2 g- 0 HA E J a v  F  ( ,2 9 = D sE L o t   3" # 3/ 2 cO V b  y = l# &* L0 H4 F= 7J "W q F, <5 +P   ) A, 3U ] ] A^ _b Gs >u  6   q! C F L] } ! d- - 	= }A N `R )l r B C <O S Db `i Sm m   l p0 @ ] l Kp c} c  -  * I P p $ + /- A VH O U Z  ] * - 0 4 6 8 +H T e x   |  1 7 ? 2E c f  h i Iu } ~  . 4 ; B S 4j m kn    	 u 7 A C F h q   !  n $ k) - 6 : L ]R Z n P    e r# - hJ R Y 7] /c p w =   n Ys *  ) 3 [ ] ] t  9  4 = ;C zk r w z   H  5( >> FF xX e 2   " {* 7 YD UM st Ix q
  ; w" H- 4 g4 NZ vo .y U4 L X s x      L* I+ F, K %b c }   g > M ?a c d h fh  	 * 9/ < F u y    , @= JI [  }  s , H6 ; H ~I \ am n ]p r y {   
  " % s/ H I 7T l r   k  - E ] _  +  B 5 j J$ ", : A m {   {S     e" x> @ c @c Rt t e/ 1 {> J `S S si n +  k @ 0 :  K  i p 3  ^  A1 2Z a o =| ~    4 ]8 'D I |K (V :V $] n     # ^ U ' < F I N X i   I  % , mC J L N T  q ~ n  i _  `! T* h+ l- }/ T ub s w p  " & , uL N O ]U f w z v{ x    J, ? 4F I U Y 6_ zs q 2 $ :2 < D 2c "d o   R n- A 2D 9F iS n br w   c1 FG Y ] e s S|   m f  j& )/ 7 L? pG G I T ^ Oz ~  d  " $& Z7 H J M b_ p  0   )# ,% D J HK _ uf h 4v  e T) p5 `< > J M Kz  2 G3 56 N Z Z ] l k  M# 48 9 : A .F wG LR U \ b Te i Hm !~ a ? , 0 2 > T O` r ,{   = n@ I t] f k x  [  $ ' jG ] o| S   I  ! . ?B B D PI [     6 =: R h s 	  e$ 
B C R 0_ _ ;c Uz     % & 3 L wM dj v }     * - 0 7 7 @ ME w[ i   N  { a4 Z8 : D (K z[ b o t v y  F   yE g s {  ! r# B8 ; E KR ` w L  Y R < }4 6 R fn  Y ! !%  & 0 ;7 n u  ]) z* 2 4 U U !i dv w ~ 
 x . ,; h [j q i{ | |  : ?N V w ? 6  . 7 L g Mm  	 v< M wb b Ly      # # e0 N3 c; D F l 0 
 \ :i n q  C  $ D O X [ Me z { 	  ] @ u C S $ E% ' , . 3 Pd V 
   # %  ( I NP X ^ b` f (m Hx  '* W< V <W d q wt u C; > 	i k  w Uw ~ 0
 | "- 5 7 M !] e m   i0 L4 S S 'a l m w   k4 \m 	   v  C F A` t   && ' K+ >2 D E T LV +_ a sl ^s | } 
  # * < L R d g Mr * "+ / 3 BB E O i `k (l n w ={ & X0 2 56 U: @D I bZ p t G	 | Z2 6 < A %B TE Q _ o | g} ~ = 9 & 9 V Y i  x  q* < K oO h_ 5d i rn r xz  {   T V _  D <E 'F UO Z \ @_ Qp j   ) $ J0 GA W _ h k x =  F h gk ! :, B RV UY [ ^ c s , T  ) * 2+ _C ^ ^ a m  z > @ D E J\ Q\ ] b   	 V M ^ ` k  # 6 F G ,H _ b :o 7u     6   ) A $C M .O Hy  5# C F   * B, - 4 ZS El s   + 6 K Ym  XB C D ` j  ( n* u* Z+ /V Y \x u 2 6 ~6 F ^ nb k q Zt Fv : 
 " * . 3 F I P f 6h fh i Lm  @  ( yC ] Wo k} T   %' ) !+ 2 4 <  O ^ p   4 B R b x 3y = 7 Q e VG P U W G] J_ m r x { y q    . NG `K S ` p ^ Q $ 5? B B _ ` Hm  r d Q) : = *f }k k H 3 "5 9 +K T 9Z h Jn Iw ~ v 
0 B0 > ? ]C G O i -u |
  
 H  1$ + + >9 ; B ([ [ N\ u w e|   f7 @ L ^ e Ml  . R  # V' * 5 *8 I s  h  , /4 3A I P q      W/ 0 5 R \ br ?    i  47 i < e, j2 #p [u      B   d                     <  k              E          =  >          +  ,  v          M  N                                                                                                               @                   L                        @      @  
    @      @      @      @  :        U n k n o w n                                   G  z                  T i m e s   N e w   R o m a n   5                       S y m b o l   3&  z                  A r i a l   ?&  
                     A r i a l   B l a c k   A&                      A r i a l   N a r r o w   ;&                        A g e n c y   F B   5&  z a               T a h o m a   "  1   h    ""    :            :                                                                                                                                                                                                                                                                                                                                        hx  4    d      9  9                                                                       2Q                               HX    	 ?    S                             ) N a m e   o f   t h e   c o n s u m e r ,   a n d   M e d i c a i d   n u m b e r        H e l e n   R i v e r a  H e l e n   R i v e r a                                                                                                                                                                                                                                                                                                                                                           Oh +'0                                                   4  	   L     X  
   x                                             ,   Name of the consumer, and Medicaid number                   Helen Rivera                              Medicaid Problem Form.dot         Helen Rivera          3         Microsoft Office 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company                 9     '                                  *   Name of the consumer, and Medicaid number            Title                       8      @            _PID_HLINKS      A            <     c                      m a i l t o : h r i v e r a @ a r c n j . o r g             @   \ ~    `                      m a i l t o : b r o b e r t s @ a r c n j . o r g           @                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                	   
                                                                      !   "   #   $   %   &   '   (   *   +   ,   -   .   /   0   1   2   3   4   5   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z   [   \   ^   _   `   a   b   c   d   f   g   h   i   j   k   l   o   R o o t   E n t r y                                                 	           F            P]Rq          D a t a                                                         
                                     )         1 T a b l e                                                                                                6   L      W o r d D o c u m e n t                                                                                        ;P       S u m m a r y I n f o r m a t i o n                           (                                     ]           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        e           C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                           
