Transcription of Application - WSHIP
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Application - WSHIP
WSHIP -18 Medicare Application Page 1 Application Medicare-Eligible Basic Plan Questions? Call 1-800-877-5187 Please type or PRINT in black ink. All sections must be filled out completely. Your premium and required documents should be included with your signed Application . Timely and complete submission of all documents will expedite the enrollment process.
WSHIP-18 Medicare Application Page 2 SECTION 3: DEPENDENT INFORMATION (if more than two, list on separate sheet or copy page)
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