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 Scptac 2014-2023

Scptac 2014-2023

Use a scptac 2014 template to make your document workflow more streamlined.

HEALTH FUND 501 Shatto Place 5th Floor Los Angeles CA 90020 800 595-7473 213 385-6161 Fax 213 487-3640 www. Please see plan rules for additional information* PART 1 PLAN PARTICIPANT INFORMATION NAME SSN ADDRESS Street City State ZIP only the last four digits are required - PART 2 PATIENT INFORMATION PART 3 MEDICATION INFORMATION Attach itemized prescription receipts or computer printouts to this form and forward to the Fund Office at the above address. Receipts and printouts must include the...
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