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Earmark Shipping to Provider: Yes No Send completed form to: Peach State Health Plan Pharmacy Department Earmark Shipping to Member: Yes No Fax: 18663741579 Office Stock/Buy & Bill: Requested Therapy
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To fill out the groupfacilityhospital name, follow these steps:

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Locate the designated field for the groupfacilityhospital name on the form or document.
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Carefully type or write the name of the hospital or healthcare facility that belongs to a specific group or organization.
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Patients or individuals who are required to specify the hospital or healthcare facility they are affiliated with when filling out various forms or documents.
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