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Requested. Section B: Eligible Family Member(s) Information List Eligible Family Member(s) who are enrolling. You may attach an additional sheet if necessary. If declining any medical coverage offered you, your spouse, or your Eligible Family Member(s), do not fill out Section B with this information. You must complete Section E Waiver of Coverage. HPN HMO or POS Plans Only: Primary Care Physician (PCP) selection is not required for HPN Open Access or SHL Plans. Select a PCP from the HPN Provid.

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