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R any assistance provided; Choose or recommend a health insurance plan for me. I understand that I must report accurate information on this application, and I must respond to any notice of missing or inaccurate information, when asked. I may cancel permission for the Community Partner Organization to help me at any time if I am enrolled in a Public Medical Program. If I cancel this permission, I will tell OHA by calling 1-800-699-9075 or by faxing my request to 503-378-5628. I understand tha.

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