OMB #: 0935-0108
M:\7690\7690.19.04\MPC 2005\Forms\Pharm\2005 Pharm Return Form.doc - 6/9/2006 - 2:38 PM - SH
If faxing material, please use this as your cover sheet.
Cover Sheet Plus ________________ Page(s)
TO
_______________________________________________________________
Data Collection Specialist
FAX NUMBER
1-800-292-6408
FROM
________________________________________________________________
________________________________________________________________
DATE
_________________________________
If mailing material, please include this cover sheet in your envelope.
Please send to:
Anne Denbow
WESTAT
9274 Gaither Road, GA89
Gaithersburg, MD 20877-1420
OFFICE USE ONLY
Provider Name
________________________________________
ID/W
________________________________________________
Connected Case
Y _______
N _______
| File Type | application/pdf |
| File Title | Cover Sheet Plus ________________ Page(s) |
| Author | tatiana watson |
| File Modified | 2006-06-09 |
| File Created | 2006-06-09 |