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INSTRUCTIONS
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Please complete sections 2, 3, 4 (if including dependents), and 9.
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In section 3 please indicate your plan category and enter in your plan name on the far left hand side.
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If including dependents please complete section 4 and include dependent name, date of birth, and social security number.
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if your enrollment is in HMO plan you must complete section 4 and include PCP name, PCP NPI, and Medical Group # and must complete for all dependents.
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