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Box 14480, Salem, OR 97309Or fax to 503-947-7514Or email to  HYPERLINK "mailto:dcbs.edimedical@oregon.gov" dcbs.edimedical@oregon.gov4015440-4015 (10/13/DCBS/WCD/WEB)      FILENAME \p \* MERGEFORMAT S:\Wcd_forms\List of Forms\4015.doc  PAGE \* MERGEFORMAT 1 PZRZTZ^Z`ZbZdZfZhZjZnZpZ[[$[&[([[[[[[[[[ϳϬyrnfnf]frRK hChZ?hhfQCJ0aJ0hShk0JjhkUhk h>j7hZ? h>j7h" h>j7hfQhC hhChf hhfhNhfCJaJhJ hhJ7jhfQhfQ5CJOJQJU^JaJmHnHu,jhfQhfQ5CJOJQJU^JaJ2j?hfQhfQ5CJOJQJU^JaJbZdZfZhZTKK $Ifgdkd @$$Ifl1rFp>**^ t44 lap2ytChZjZlZnZpZ0bkdA$$Ifl10*) t44 lapyt( $IfgdbkdA$$Ifl0*) t44 lapytFjpZ[[[[\\[RA"$If^`"gdC $Ifgd"HkdYB$$Ifl*+ t44 lap ytFj $IfgdfQHkdB$$Ifl*+ t44 lap ytFj $Ifgdk[[[\\\\\\\\\\\\]](]H]`]b]]]]]]]]]]ЮɤxfbWOh!CJaJhhr(CJ0aJ0hr(#hh"5CJ0OJQJ^JaJ0h"5CJ0OJQJ^JaJ0 hChkhShk0Jhkhk>* hk>*jhk>*UhChr(5hh"CJ0aJ0hCh"5 hChr( hCh"hhNCJ0aJ0hC hChNhChN5hhZ?CJ0aJ0\\\\\\]LC: $Ifgdk $Ifgd<]`kdC$$Ifl0<*`' t44 lapytFj $IfgdfQHkdB$$Ifl*+ t44 lap ytFj]]]]]yne $Ifgd<] <$IfgdNzkdC$$Ifl4F<%*\"` t    44 lapytFj $$Ifa$gd]]]]] $Ifgd<] $IfgdUubkd!D$$Ifl40%*&  t44 lapytFj]]]]]]]]]]^^^ ^D^F^^^^^^^^^^^^ʽʽjhfUmHnHuh++mHnHuhfjhfUhjhUhQhCJaJhUuhhUuCJaJhCCJaJ]]]]]]]^^^^^^^^|$a$zkdD$$Ifl4F; %* ]  t    44 lapytFj^^9 0&P1h:p"/ =!"#$% 3"DdP h  C DA,DCBS logo black - WCDbw!?$\O\ *m2jS!DenK!?$\O\ *m2jPNG  IHDR<0 IDATxy|Tgfl$NYJ@F"-i>||O\Z+b))}$Uv H Ls03ĺzs=={{s9şx<1_V=nCtt5557.>tP-[bN'SL)KMM<..Y]g'6 #>,? 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