Medicare Letter

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    *The information I provided above is accurate and to the best of my knowledge correct. I hereby hold harmless David A. Crotts & associates Inc. for any misrepresented information. In addition, I also granted permission to David a. Crotts & Associates Inc. to contact me about my insurance and or other insurance related matters.

    PRESCRIPTION DRUG LIST

    (Please list all medications as listed on Rx Bottle)