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Enrollment Questions
Let's check your doctors and prescriptions to make sure that you are in a plan that covers them correctly. Thank you for taking the time to fill out this form.
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What is your name?
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Your answer
Who is your primary care doctor?
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Your answer
Do you go to any specialists? If so, who are they or what facility are they at?
Your answer
List current prescription names and dosage. If you don't take any, type none.
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Your answer
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