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OMB No. 0938NEW
Expires: 07/31/2023INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL
IN A MEDICARE PRESCRIPTION DRUG PLAN (PART D)
Who can use this form? Reminders:People with Medicare who want to join
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What is online enrollment-form-s5617-en fax email?
The online enrollment-form-s5617-en fax email is a specific form used for enrolling in certain programs or services, allowing individuals to submit their application via fax or email.
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Individuals or entities who wish to enroll in the specified programs associated with the online enrollment-form-s5617-en are required to file this form.
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To fill out the online enrollment-form-s5617-en fax email, follow the guidelines provided in the form, ensuring that all required fields are completed accurately before submitting it via fax or email.
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The purpose of the online enrollment-form-s5617-en fax email is to facilitate the enrollment process for programs, making it easier for applicants to submit necessary information.
What information must be reported on online enrollment-form-s5617-en fax email?
The information that must be reported includes personal identification details, contact information, and any specific program-related information requested in the form.
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