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The time you receive the response to allow for mail time plus claims processing. * Keep a copy of all documents submitted for your records. * Do not staple or tape receipts or attachments to this form. STEP 1 Card Holder/Patient Information This section must be fully completed to ensure proper reimbursement of your claim. Card Holder Information Identi cation Number (refer to your prescription card) Group No./Group Name Name (Last Name) (First Name) (MI) Address State City Zip Patie.

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