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HARMACY OR DO NOT USE YOUR PRE- SCRIPTION DRUG CARD, COMPLETE A SEPARATE PRESCRIPTION DRUG CLAIM FORM. 3. IF YOU WANT BENEFITS PAID TO YOUR DOCTOR, OR PROVIDER DIRECTLY, BE SURE TO SIGN ITEM 17. 4. COMPLETE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER. 5. THE COMPLETED CLAIM FORM SHOULD BE RETURNED TO: POMCO P.O. BOX 6329 SYRACUSE, NY 13217 TOLL FREE NUMBER 1-800-234-9862 IMPORTANT REMINDER: PLEASE BE SURE THE EMPLOYEE'S SOCIAL SECURITY NUMBER HAS BEEN PROVIDED. "ANY PERSON WHO KNOWINGL.

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