H0271 060 - COVERAGE Cigna Preferred Savings Medicare (HMO) H0354-029 1 Summary of Benefits H0354_23_791307_M Reducing your Medicare Part B premium; no referrals required

 
2023 New York UnitedHealthcare Dual Complete® Plan Frequently Asked Questions: H0271-060-001 Subject: UnitedHealthcare Community Plan of New York manages the Medicare Advantage benefits and reimburses you according to your existing contracted rates. Created Date: 20230220173758Z. Carmenpercent27s cantina

Jan 1, 2023 · Y0066_SB_H0271_045_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Monday – Friday 8 a.m. – 6 p.m. EST 1-888-617-8979 TTY 711. To learn more about applying for health insurance, including Medicaid, Child Health Plus, Essential Plan, and Qualified Health Plans through NY State of Health, The Official Health Plan Marketplace, visit www.nystateofhealth.ny.gov or call 1-855-355-5777.UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll. Number of Members enrolled in this plan in (H0271 - 027): 4,053 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 3 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ...UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.UnitedHealthcare - H0271 En el año 2023, UnitedHealthcare - H0271 recibió las siguientes Calificaciones con Estrellas de Medicare: Calificación General por Estrellas: 4 estrellas Calificación de los Servicios de Salud: 3.5 estrellas Calificación de los Servicios de Medicamentos: 3 estrellas COVERAGE Cigna Preferred Savings Medicare (HMO) H0354-029 1 Summary of Benefits H0354_23_791307_M Reducing your Medicare Part B premium; no referrals requiredY0066_EOC_H0271_046_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of CoverageUnitedHealthcare Chronic Complete Assure (PPO C-SNP) 4 out of 5 stars. UnitedHealthcare Chronic Complete Assure (PPO C-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare. Plan ID: H0271-027. $ 9.80. Monthly Premium. UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll. Y0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ...Jan 1, 2023 · h0271-060-001 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Jan 1, 2023 · Y0066_SB_H0271_013_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Service area: New York - Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung,UnitedHealthcare Chronic Complete Assure (PPO C-SNP) 4 out of 5 stars. UnitedHealthcare Chronic Complete Assure (PPO C-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare. Plan ID: H0271-027. $ 9.80. Monthly Premium. This page features plan details for 2023 UnitedHealthcare Dual Complete Choice (PPO D-SNP) H0271 – 060 – 2 available in Select Counties Downstate NY. IMPORTANT : This page has been updated with plan and premium data for 2023.2023 UnitedHealthcare (H0271) Star Rating Details; UnitedHealthcare Dual Complete Choice (PPO D-SNP) (H0271-060-1) Benefits & Contact Info The UnitedHealthcare Dual Complete Choice (PPO D-SNP) (H0271-060-1) in Putnam, NY: CMS MA Region 3 which includes: NY: Star Rating Category & Measures: 2023: 2022: Overall Star Rating: 4: 4Y0066_EOC_H0271_060_001_2023_SP_C. OMB Approval 0938-1051 (Expires: February 29, 2024) Del 1 de enero al 31 de diciembre de 2023 Evidencia de CoberturaJan 1, 2023 · h0271-029-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Jan 1, 2023 · Y0066_SB_H0271_045_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.COVERAGE Cigna Preferred Savings Medicare (HMO) H0354-029 1 Summary of Benefits H0354_23_791307_M Reducing your Medicare Part B premium; no referrals required2023 New York UnitedHealthcare Dual Complete® Plan Frequently Asked Questions: H0271-060-001 Subject: UnitedHealthcare Community Plan of New York manages the Medicare Advantage benefits and reimburses you according to your existing contracted rates. Created Date: 20230220173758Z Plan ID: H0271-060-002. * Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. $0.00 Monthly Premium. New York Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A ... 2023 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete Choice (PPO D-SNP) Location: Essex, New York Click to see other locations. Plan ID: H0271 - 060 - 1 Click to see other plans. Member Services: 1-800-514-4912 TTY users 711. Y0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... UnitedHealthcare - H0271 For 2023, UnitedHealthcare - H0271 received the following Star Ratings from Medicare: Overall Star Rating: 4 stars Health Services Rating: 3.5 stars Drug Services Rating: 3 stars Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings are Important Medicare rates plans on their health and ...The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage.Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Service area: New York - Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung,The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage. 5. Introduction. SHIBA (Senior Health Insurance Benefits Assistance) is a statewide network of certified . counselors volunteering in their community to help all Oregonians make educatedEnrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Service area: New York - Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung,Y0066_EOC_H0271_060_002_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage Resumen de Beneficios 2023 UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud queo UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 - UO7 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security NumberGuía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Área de servicio: New York - condados de Albany, Allegany, Broome, Cattaraugus, Cayuga,H0271 027 * 4. Christian. UnitedHealthcare; UnitedHealthcare Chronic Complete Assure (PPO C-SNP) Local PPO Chronic or Disabling Condition $ 9.80 $ 505.00 No; DS H0271; Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $3000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined.Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 Área de servicio: New York - condados de Bronx, Kings, Nassau, New York, Queens y Richmondh0271 023 014 ct in me 020 028 mi 029 030 mt 016 sc 037 sd 038 ut 013 wv 042 wy 039 024 h0321 arizona physicians ipa, inc. az h0423 metroplus health plan, inc. h0432 009 h0439 cigna healthcare of georgia, inc. h0473 humana insurance company of kentucky h0482 centene venture company michigan h0524 kaiser foundation hp, inc. ca h0544 blue cross ...Number of Members enrolled in this plan in (H0271 - 057): 3,821 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 3 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... h0271-060-002 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.Jan 1, 2023 · h0271-060-001 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage.Y0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... H0271-060: Download: UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) 2023: R5342-001: Download: UnitedHealthcare Medicare Advantage Choice Plan 4 ...h0271-060-002 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.Y0066_SB_H0271_036_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ...Number of Members enrolled in this plan in (H0271 - 029): 31,066 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 3 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Service area: New York - Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung,UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.o UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 - UO7 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ FemeninoY0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ...h0271-043-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.Jan 1, 2023 · h0271-060-001 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Resumen de Beneficios 2023 UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que Y0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Jan 1, 2023 · Y0066_SB_H0271_027_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... H0271 027 * 4. Christian. UnitedHealthcare; UnitedHealthcare Chronic Complete Assure (PPO C-SNP) Local PPO Chronic or Disabling Condition $ 9.80 $ 505.00 No; DS H0271;h0271 023 014 ct in me 020 028 mi 029 030 mt 016 sc 037 sd 038 ut 013 wv 042 wy 039 024 h0321 arizona physicians ipa, inc. az h0423 metroplus health plan, inc. h0432 009 h0439 cigna healthcare of georgia, inc. h0473 humana insurance company of kentucky h0482 centene venture company michigan h0524 kaiser foundation hp, inc. ca h0544 blue cross ...h0271 023 014 ct in me 020 028 mi 029 030 mt 016 sc 037 sd 038 ut 013 wv 042 wy 039 024 h0321 arizona physicians ipa, inc. az h0423 metroplus health plan, inc. h0432 009 h0439 cigna healthcare of georgia, inc. h0473 humana insurance company of kentucky h0482 centene venture company michigan h0524 kaiser foundation hp, inc. ca h0544 blue cross ...The following UnitedHealthCare plans are accepted at Oak Street Health locations. Plan Name. Effective Year. Benefit Package. Summary. AARP Medicare Advantage. 2023. H1944-024. AARP Medicare Advantage.UnitedHealthcare offers UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 Lookup Tools plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about lookup tools.Y0066_EOC_H0271_060_001_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of CoverageY0066_EOC_H0271_046_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the UnitedHealthcare Medicare Advantage Assure (PPO) benefit details. — Medicare Plan Features —. Monthly Premium: $29.10 (see Plan Premium Details below) Annual Deductible: $480. Annual Initial Coverage Limit (ICL): UnitedHealthcare - H0271 En el año 2023, UnitedHealthcare - H0271 recibió las siguientes Calificaciones con Estrellas de Medicare: Calificación General por Estrellas: 4 estrellas Calificación de los Servicios de Salud: 3.5 estrellas Calificación de los Servicios de Medicamentos: 3 estrellas Sep 1, 2023 · What you'll pay. Dental $3,000 per year for covered dental services. $0 copay for covered network preventive services including oral exams, routine cleanings, X-rays and fluoride. $0 copay for covered network comprehensive services such as fillings, crowns, root canals, extractions, dentures and implants. h0271-060-002 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-001 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll. TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the UnitedHealthcare Medicare Advantage Assure (PPO) benefit details. — Medicare Plan Features —. Monthly Premium: $29.10 (see Plan Premium Details below) Annual Deductible: $480. Annual Initial Coverage Limit (ICL):Y0066_SB_H0271_013_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ...Jan 1, 2023 · Y0066_SB_H0271_036_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Number of Members enrolled in this plan in (H0271 - 027): 4,053 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 3 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ...Jan 1, 2023 · Y0066_SB_H0271_045_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Y0066_EOC_H0271_060_001_2023_SP_C. OMB Approval 0938-1051 (Expires: February 29, 2024) Del 1 de enero al 31 de diciembre de 2023 Evidencia de CoberturaResumen de Beneficios 2023 UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud quePlan ID: H0271-060-001. * Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. $0.00 Monthly Premium. New York Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A ...This page features plan details for 2023 UnitedHealthcare Dual Complete Choice (PPO D-SNP) H0271 – 060 – 2 available in Select Counties Downstate NY. IMPORTANT : This page has been updated with plan and premium data for 2023.Jan 1, 2023 · Y0066_SB_H0271_036_000_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ... Call (518) 346-2115 for Medicare Advantage, Supplement & Part D Plans in NY MA NJ or FLResumen de Beneficios 2023 UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud queCSNY23PP0049826_000 Página 1 de 8 Solicitud de Inscripción 2023 o UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 - UO7 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul)Y0066_EOC_H0271_060_001_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage Y0066_EOC_H0271_046_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage2023 UnitedHealthcare (H0271) Star Rating Details; UnitedHealthcare Dual Complete Choice (PPO D-SNP) (H0271-060-1) Benefits & Contact Info The UnitedHealthcare Dual Complete Choice (PPO D-SNP) (H0271-060-1) in Putnam, NY: CMS MA Region 3 which includes: NY: Star Rating Category & Measures: 2023: 2022: Overall Star Rating: 4: 4UnitedHealthcare Dual Complete® Choice (PPO D-SNP) dummy spacing Benefits In-Network Out-of-Network Inpatient Hospital Care2 $0 copay - $1,556 copay per stay 40% coinsurance perY0066_SB_H0271_060_001_2023_M. Summary of Benefits January 1st, 2023 - December 31st, 2023 This is a summary of what we cover and what you pay. Review the Evidence of ...

Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Área de servicio: New York - condados de Albany, Allegany, Broome, Cattaraugus, Cayuga, . Dbd loudest survivor

h0271 060

h0271-060-001 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.Number of Members enrolled in this plan in (H0271 - 029): 31,066 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 3 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-001 Service area: New York - Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung,Learn more about the UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 plan for New York. Check eligibility, explore benefits, and enroll today. Jan 1, 2023 · h0271-060-002 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 Área de servicio: New York - condados de Bronx, Kings, Nassau, New York, Queens y Richmondh0271-043-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.UnitedHealthcare offers UnitedHealthcare Dual Complete® (HMO D-SNP) H0271-060-002 plans for New York and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the UnitedHealthcare Medicare Advantage Assure (PPO) benefit details. — Medicare Plan Features —. Monthly Premium: $29.10 (see Plan Premium Details below) Annual Deductible: $480. Annual Initial Coverage Limit (ICL):CSNY23PP0049826_000 Página 1 de 8 Solicitud de Inscripción 2023 o UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 - UO7 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul)UnitedHealthcare - H0271 En el año 2023, UnitedHealthcare - H0271 recibió las siguientes Calificaciones con Estrellas de Medicare: Calificación General por Estrellas: 4 estrellas Calificación de los Servicios de Salud: 3.5 estrellas Calificación de los Servicios de Medicamentos: 3 estrellas o UnitedHealthcare Dual Complete® Choice (PPO D-SNP) H0271-060-002 - UO7 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number .

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