Detailed Information Pertaining To Forms Contained In This Submission:

If the proposed coverage includes a Preferred Provider Arrangement
please complete the information below:

Complete information on the network and service area are enclosed with this submission

The Network and service area are the same as that currently used with other previously approved forms. Please identify the Department file number and approval date of the submission that contains the network and service area information.

Department File #:      Approval Date:

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