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Health Tradition for Individuals and Families AGENT OF RECORD Please complete print and submit. Reset Form Print Send to Health Tradition Health Plan PO Box 188 La Crosse WI 54602-0188 Fax Email 608-781-9653 Contact HealthTradition.com Member Information Last Name First Name MI Member ID Number HTW Mailing Address City State Zip Code Agent Information Agent Name NPN Number Signatures Member Signature Date X Agent Signature / 221-HTH145 08/16.
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