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2. Prescription Drug Coverage*

   Are you currently without prescription drug coverage?

   1. Yes
   2. No
3. Medical Assistance*

   Are you currently enrolled in Medical Assistance?

   1. Yes
   2. No
5. Drug Coverage Through Insurance*

   Do you currently have prescription drug coverage through your insurance provider?

   1. Yes
   2. No
6. Drug Coverage Through the VA*

   Do you currently have prescription drug coverage through the Veterans Administration?

   1. Yes
   2. No
8. First Name*
9. Last Name*
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Date of Birth*
20. Phone Number*
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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