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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE Determinations form may be sent to us by mail or fax:
Address:
P.O. Box 52000, MC109, Phoenix, AZ 850722000Fax Number:
18556337673You may also ask us
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This form may be a tax form used for reporting income.
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This form may be filled out by providing accurate information about the income received.
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The purpose of this form may be to report income to the tax authorities.
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Information such as income sources, amounts received, and deductions may be required to be reported on this form.
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