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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Express Scripts Attn: Prior Authorization Part D Mail Route B40103 8640 Evans Road

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4. Follow the form's format and instructions to provide accurate and complete information in each section.
5. Use clear and concise language when answering any questions or providing explanations.
6. Double-check your entries to ensure accuracy and correctness.
7. If any sections are not applicable to you, mark them as N/A or provide an explanation if required.
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9. Sign and date the form as instructed, and gather any additional supporting documents if necessary.
10. Submit the form by mail, online, or in person according to the provided submission instructions.

Who needs this form may be?

1. Individuals applying for a specific program or benefit that requires the completion of this form.
2. Employees or job applicants who need to provide personal information for HR or payroll purposes.
3. Students or parents/guardians filling out educational forms for admissions, financial aid, or enrollment.
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5. Government agencies requesting specific information from individuals or organizations.
6. Healthcare providers or patients filling out medical forms for documentation or treatment purposes.
7. Immigration applicants or petitioners providing information related to visas, permits, or residency.
8. Individuals seeking legal or financial assistance that requires the completion of relevant forms.
9. Researchers or survey participants contributing information for studies or data collection.
10. Anyone who is required to provide certain information in a standardized format for administrative purposes.

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What is this form may be?

This form may be a tax return form.

Who is required to file this form may be?

Individuals or businesses meeting certain criteria may be required to file this form.

How to fill out this form may be?

This form may be filled out by providing accurate information regarding income, deductions, and other relevant details.

What is the purpose of this form may be?

The purpose of this form may be to report income, calculate tax liability, and claim deductions or credits.

What information must be reported on this form may be?

Information such as income sources, deductions, credits, and tax payments must be reported on this form.