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Get Caremark Medicare Part D EFT Set-Up Request

then print, sign and fax as indicated below. EFT Request Type: New EFT Set-Up Change to Existing EFT Set-Up Cancel EFT Pharmacy Type: Independent NCPDP#: Chain NPI#: Chain Code#: Pharmacy / Chain Name: Address (street, city, state, zip):  Contact Name:  Phone:   Fax:  Contact Email Address: Pharmacy/Chain Email Address: EFT Banking Information: Bank Account #: ABA Routing Number: Account Name: Account Type: Checking Bank Name: Bank Address/Ci.

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How to fill out and sign Caremark d requestor online?

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