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Get Lehigh Valley Health Network Financial Assistance Program Application

Nce Information: (If Applicable- List All) Use extra paper if needed and include card copies Name of Company: Subscriber Name: ID Number: Group Number: Insurance Claims Address: Insurance Phone Number: Have you applied for Medical Assistance in the past 6 months? Yes No (See Other Side, Page 2) W If YES, please enclose a copy of the Letter of Denial or Proof of Eligibility (include letter or Access card). If NO, please contact your local county assistance office for guidance on how to appl.

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