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Get TX Other Source Health Insurance Information 2017-2024

Employer Address: OTHER SOURCE HEALTH INSURANCE INFORMATION Please provide this agency with the information requested below regarding your employee (obligor) within 20 business days after the date of the notice, or sooner, if reasonable. PLEASE RETURN THIS FORM TO THE ADDRESS LISTED ABOVE ***Please enclose copies of: Health insurance policy; Schedule of benefits; Insurance membership cards; Claim forms*** Child Name DOB SSN Enroll ment Date Complete the following for all children that have.

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