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PC Holder s Date of Birth D D M M Y Y Name of Person Applying for Refund (if different from above, and also state relationship to the PPC holder) Address to which refund should be sent Post Code Daytime Telephone Number Serial Number of Enclosed Pre-payment Certificate 4 months Period of Validity (tick box) 12 months Reason for Refund (tick box) Holder became entitled to free NHS Prescriptions within 1 month of PPC start date Date became exempt D D M M Y Y Date of admiss.

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