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Part D Enrollees & Representatives  /  Forms

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Enrollees & Representatives

Forms

• Prescription Drug Reconsideration Request Form (PDF)
• Prescription Drug Reconsideration Request Form - Review of Plan Dismissals (PDF)
• Late Enrollment Penalty Reconsideration Request Form (PDF)
• Appointment of Representative Form
• Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal Form