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ineligibility. The provider must use the form to show admission date, to request information on AG or Medicaid eligibility status, to request a Medicaid recipient I.D., or to notify the local DSS of changes in the individual’s circumstances, discharge or death. Note: There is no separate form labeled “Advance Notice of Proposed Action.” Sending the “Notice of Action (for AG)” 10 days prior to action is the Advance Notice. Make sure that all notification of changes are mailed out 10 days prior to action where indicated.