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E FOR COMPLETING THEIR APPROPRIATE SECTIONS OF THE APPLICATION. PATIENT AND HEALTH-CARE PROVIDER MUST SIGN THE APPLICATION FOR EACH REQUEST. HEALTH-CARE PROVIDER WILL BE ADVISED IN WRITING OF ANY DENIED REQUESTS. INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE HEALTH-CARE PROVIDER FOR COMPLETION. HEALTH-CARE PROVIDER MUST PROVIDE OFFICE HOURS AND DAYS FOR DELIVERY. PROGRAM ELIGIBILITY: PATIENT MUST BE A RESIDENT OF THE UNITED STATES. PATIENT MUST BE 19 YEARS OF AGE OR OLD.

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