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RESET FOOTPRINT Formal Service Order Formal this form to:Member ID # (if not shown or if different from above)Prescription Plan Sponsor or Company Name Instructions: Please use blue or black ink and

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What is is it necessary to?

It is necessary to comply with legal requirements and regulations.

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Any individual or entity required by law to do so.

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What is the purpose of is it necessary to?

The purpose is to ensure compliance and provide necessary information.

What information must be reported on is it necessary to?

Details as required by law or regulations.

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