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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Attn: Pharmacy Care Management Health Alliance Plan 2850 W. Grand Blvd. Detroit,

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How to fill out this form may be

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2. Gather all the necessary information and documents required to fill out the form.
3. Fill out the personal information section with accurate details such as name, address, and contact information.
4. Pay attention to any specific format or guidelines mentioned for filling out the form.
5. Provide the requested information in the appropriate sections of the form.
6. Double-check all the entered details for any errors or omissions.
7. If applicable, attach any supporting documents as mentioned in the form instructions.
8. Review the completed form to ensure everything is filled out correctly.
9. Submit the form as per the designated method mentioned in the instructions.
10. Keep a copy of the filled form for your records.

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5. Students applying for scholarships or financial aid may need to fill out this form.
6. Applicants for various types of employment may be asked to submit this form.
7. Anyone required to provide specific information or data to an authority or institution may need this form.
8. Certain applications, registrations, or requests may mandate the use of this form.
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What is this form may be?

This form may be a tax 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 online or by mail, following the instructions provided.

What is the purpose of this form may be?

The purpose of this form may be to report income or other financial information to the relevant authorities.

What information must be reported on this form may be?

Information such as income, expenses, and deductions may be required to be reported on this form.