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Click ‘Get Form’ to open form 3895 in the editor.
Begin by entering your personal information in Part I, including your name, Social Security Number (SSN), and date of birth. If applicable, include your spouse's details.
In Part II, provide coverage information for each month. Fill in the monthly enrollment premiums, second lowest cost silver plan (SLCSP) premium, and any advance payment amounts received.
Ensure all fields are accurately completed. If there are more than five covered individuals, additional forms may be required.
Review all entered information for accuracy before saving or submitting the form through our platform.
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PennCard Request Form - University of Pennsylvania
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