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Instructions Please complete this form and return it to Well partner, P.O. Box 5909, Portland, OR 97228-5909. Be sure to enclose your original prescription’s) along with payment information. To
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The purpose of make sure form patients is to ensure that patients receive the appropriate care and treatment.
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Information such as patient's medical history, treatment plan, medications, and any relevant test results must be reported on make sure form patients.
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