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HMO ENROLLMENT APPLICATION CARDHealth Alliance Plan Check one or both. Enrolling for:Last Name MedicalLegal First and Middle InitialSocial Security No. Phone(AddressStateApt. Childbirth Date)ZipMaleqFemaleqGroup

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What is enrollment application card?

Enrollment application card is a form used to apply for enrollment in a program or service.

Who is required to file enrollment application card?

Individuals seeking to enroll in a program or service are required to file enrollment application card.

How to fill out enrollment application card?

Fill out the enrollment application card with accurate and complete information as requested on the form.

What is the purpose of enrollment application card?

The purpose of the enrollment application card is to gather essential information from individuals seeking to enroll in a program or service.

What information must be reported on enrollment application card?

The enrollment application card must include personal details, contact information, program preferences, and any required supporting documentation.

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