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R to the last page of this document. If you are blind or vision impaired and need this form in another format such as Braille, large font print or an electronic format, or you need assistance filling out this form, please call 1-855-7950634. If you would like free legal help, call Covered California at 1-800-300-1506 and we will refer you to your local legal aid or welfare rights office. Yes No Does your appeal need to be expedited?* * If you have an immediate need for health services.

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