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PLEASE DO NOT FAX THIS PAGE BACKDATING ASSISTANCE PROGRAM INSTRUCTIONS Application must be completed, signed and dated by both the Healthcare Professional and Patient. Patient must submit one of the
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Follow the submission instructions provided with the application form to send it to the designated authority.
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Who needs application must be completed?
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Anyone who is required to fulfill a particular purpose or meet specific criteria as outlined in the application instructions needs to complete the application form.
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The specific requirements and eligibility criteria for completing the application will be mentioned in the instructions or guidelines provided.
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