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PRESCRIPTION DRUG CLAIM FORMS WILL ONLY BE ACCEPTED ONCE A YEAR TO OBTAIN MAXIMUM BENEFITS CLAIMS SHOULD BE SUBMITTED IN ACCORDANCE WITH THE RULES DESCRIBED ABOVE. ONE FORM PER FAMILY - MEMBER MUST COMPLETE THIS SECTION Member s Name Social Security Number Home Address City Name of School or Building Assignment State Date of Employment in Yonkers System Zip Code Date Of Birth Home Phone This Claim is For Member Only Family Amount Claimed I am cov.

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