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Get Po Box 30990 Salt Lake City

From the eyewear provider and send to the address above. If your plan includes eyewear coverage, coverage is available for members under age 19 and includes frames, lenses OR contact lenses when prescribed solely for vision correction, as well as any related fittings. A. SUBSCRIBER/PATIENT INFORMATION Subscriber s Name: (Last, First, Middle Initial) Patient s ID number: Patient s Name: (Last, First, Middle Initial) Address: Patient s Relationship to Subscriber (Check box) Self.

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