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Af and hearingimpaired individuals may use a TDD/TTY by calling 1-800-410-1681. Questions, concerns, complaints, or requests for information in alternative formats must be directed to 1-800-842-1508. If you have any questions about this application or need help completing it, call 1-800-656-6684. If the information you have does not fit on this form, please attach separate sheets of paper as needed. Section A: - I want health insurance for: (Check (3) the category or categories that match your.

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