
Get the free S2668FBTNFL16014v1PDP Model Enrollment FormExhibit 1Revised.docx
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Farm Bureau Health Plans
Medicare Prescription Drug Plan Individual Enrollment Form Please contact
Farm Bureau Health Plans, if you need information in another language or format (Braille). To Enroll
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This form is a model enrollment exhibit for s2668fbtnfl16014v1pdp.
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Entities or individuals specified in the regulations are required to file this form.
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The purpose of this form is to enroll in the s2668fbtnfl16014v1pdp program.
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The form requires reporting specific enrollment information as outlined in the instructions.
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