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INFORMATION A. Sex: M F Member Name: Date of Birth: Mailing Address Medical Record Number: City: State: Employer Group/Trust Fund Name (If applicable): Employer Group/Trust Fund Number (if applicable): Zip: Do you have other prescription drug coverage? Yes No If yes, please provide the name of other coverage: Has this claim been submitted to the other coverage carrier? Yes No If Yes, please indicate the amount the carrier reimbursed you? $ B.

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