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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES TRANSMITTAL FORM TAR APPEAL INSTRUCTIONS Each group of TARs presented via Mail Fax or Onsite to the Field Office Pharmacy Section or Appeals TAR Administrative Remedy Section may include this form. Providers who would like to receive a copy of the Transmittal Form as an acknowledgement of receipt of TARs must send 2 copies of the Transmittal Form and a self ad.

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