CONTACT
INFO |
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Address: |
, |
Phone: |
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Provider Phone: |
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Fax: |
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Website: |
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ELIGIBILITY
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Eligibility
Info: |
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Income at or below: |
Single |
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% FPL |
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Couple |
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% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
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Social security requested on form: |
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US citizenship/residency specified:
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APPLICATION |
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Attachments
Required: |
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Physician
License #
Required: |
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Prescriber
Signature
Allowed: |
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Application
may be
faxed: |
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Eligibility
determination
letter sent: |
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MEDICATION |
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Receives: |
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Shipped To: |
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Quantity in
Shipment: |
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Delivery Time: |
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Re-application
Policy: |
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Refill Policy: |
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Other Information: |
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