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, I will not be able to participate in the Program. I understand that I may revoke this authorization, in writing, at any time, except to the extent action has been taken in reliance on it, by addressing such revocation to Patient Assistance Program 250 Phillips Blvd, Ste 250, Ewing, NJ 08618 (your healthcare professional will be advised) and that only a written revocation addressed to the Program will constitute an effective withdrawal of my authorization. I understand that I may req.

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