South Carolina Department Of Health And Human Services Medical Support Referral For Low Income Families Page 2

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Directions to Home and Absent Parent / Remarks:
I understand that I am protected by Title VI of the Civil Rights Act, and I will make written complaints to the State Director, South
Carolina Department of Health and Human Services, Post Office Box 8206, Columbia, South Carolina 29202-1520, within 180 days
if at any time I am denied services or otherwise discriminated against because of race, color, creed, sex, religion or national origin.
INSTRUCTIONS
Applicants:
1. Complete each field on the form.
2. Return the form to your Medicaid eligibility worker.
Medicaid Eligibility Worker:
1. Review form to ensure each field is completed.
2. Send or deliver the completed form to the South Carolina Department of Social Services to one of the
addresses listed below.
By courier service to:
South Carolina Department of Social Services
Child Support Enforcement Division
3150 Harden Street
Columbia, South Carolina 29202
By mail to:
South Carolina Department of Social Services
Child Support Enforcement Division
Post Office Box 1469
Columbia, South Carolina 29202-1469
DHHS Form 2700 ME (September 2007))
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