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MEDICARE PRESCRIPTION DRUG COVERAGE WORKSHEET 1. What is your name as it appears on your Medicare card 2. I give the provided. I confirm that all information provided is truthful and accurate and I hereby release the SHICK Counselor the SHICK organization and the State of Kansas from any liability whatsoever known or unknown related or pertaining my Medicare Part D enrollment herein. I also acknowledge that information discussed with the Counselor cannot be relied upon nor construed as legal...
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My name is Virtual Assistant.
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Your full legal name as it appears on official documents.
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