Form Cms-1666 - Regional Office Request For Additional Information Page 2

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REPLY TO REQUEST FOR ADDITIONAL INFORMATION OR OTHER ACTION
TO
ASSOCIATE REGIONAL ADMINISTRATOR
DIVISION OF MEDICAID AND STATE OPERATIONS
FROM (Name and address of State Agency or Regional Office)
IN RESPONSE TO THE REQUEST ON THE REVERSE SIDE, THE FOLLOWING INFORMATION IS SUBMITTED:
SIGNATURE OF STATE AGENCY OR REGIONAL OFFICE REPRESENTATIVE
TITLE
DATE OF TRANSMITTAL

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