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Medicare Prescription Drug Plan Use Only: Check here if this applicant was referred by a producer. Effective Date of Coverage: Date: / / IEP AEP SEP (type): Assigned #: Plan Representative Signature:
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Applicant Signature Name (required): Signature of Produce her Signature (required): Address (if different from above; not the applicant home address): Signature of Applicant (required): Signature of Produce RER (required): County or Zip/Postal Code (if a zip code is specified in the Application): Signature of Applicant (required): Date: / / CISP (Congressional Stop Online Pharmacy Expansion Act) Application Package For all questions and comments with respect to the National Drug Code (NDC), you may send your completed I-129 Application Package to: I-129 (Application Package for National Drug Code) National Institute on Drug Abuse Office of Research and Drug Development CERAS Reference Number 03-934 1600 Clifton Rd., Bldg. 1234 Rockville, MD 20850 Telephone: Email: Internet: (last visited April 28, 2012) Please direct all requests to I-129 (Application Package for National Drug Code) above. For questions and comments regarding the ICD-10 System for Diagnosis and Classification of Diseases and Disorders (SIDE) check the FAQs. Information in this FAQs () and in the I-129 (Application Package for National Drug Code) may be updated and/or edited for future issues at any time, solely at the sole discretion of the I-129 (Application Package for National Drug Code) Coordinator. If you are not satisfied with the I-129 (Application Package for National Drug Code) Coordinator's handling of your request, please report the event to I-129 (Application Package for National Drug Code) Coordinator, National Institute on Drug Abuse, 200 C Street, N.W., Room 2-0513, N.E., Office of Research and Drug Development, National Institutes of Health, 200 C Street, N.W., NIDA Research Reference # 03-931 (This information is exempt from publication in Pub. L. [cited in the final rule] (45 Code of Fed. Reg. At 39,847)) This form is intended for use only by persons with the required authorization and is not a substitute for formal medical diagnosis from a physician.

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Individual enrollment form is a document used to register an individual for a specific program, service, or event.
Any individual who wishes to enroll in a particular program, service, or event may be required to file an individual enrollment form.
To fill out an individual enrollment form, you need to provide the required information specified on the form. This can include personal details, contact information, and any additional information that may be necessary for enrollment.
The purpose of an individual enrollment form is to collect necessary information from individuals who wish to enroll in a specific program, service, or event. It helps in the organization and management of enrollments.
The specific information to be reported on an individual enrollment form may vary depending on the program, service, or event. Generally, it includes personal details such as name, address, contact information, and any other relevant information related to the enrollment.
The deadline to file the individual enrollment form in 2023 may vary depending on the specific program, service, or event. It is recommended to refer to the official guidelines or contact the organizing entity for accurate information.
The penalties for the late filing of an individual enrollment form may vary depending on the governing rules and regulations of the program, service, or event. It is advisable to review the guidelines or consult with the organizing entity to understand the specific penalties involved.
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