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Office Use Only Name of Staff Member/Agent/Broker If assisted in enrollment Broker ID Receipt Date AEP SEP type ICEP/IEP/IEP2 Please Read and Answer These Important Questions 1. Ms. Mrs. Date of Birth mm/dd/yyyy Home Phone xxx-xxx-xxxx MI Sex Male Female First Name Email Permanent Residence Address P. DO NOT pay HeartlandPlains Health the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. Care from HeartlandPlains Health physicians...

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