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Ent Assistance Program ( Program ) is entitled at any time to request verification of any such information which I agree to provide from me, my employer, and/or my insurer. I understand that the program may contact me for verification of my application status and receipt of the indicated drug(s) and/or device(s). I understand that if approved, I am not eligible to, and I certify that I will not seek reimbursement for any drug(s) and/or device(s) requested on the prescription attached to this.

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