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Important Information about Prescription Drug Coverage To: Fax: Fax completed form to: 18556337673 Questions, please call: 18553440930 24 hours a day 7 days a week TTY users call: 18662361069 From:
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The completed form should be faxed to the designated fax number.
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The purpose of the form is to report necessary information to the relevant authorities.
The form may require reporting of personal information, financial details, or other relevant data.
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