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ENTER CALENDAR YEAR ________ This tax report form must be filed by the following types of insurers ONLY: HEALTH CARE SERVICES ORGANIZATION PREPAID DENTAL PLAN ORGANIZATION HOSPITAL, MEDICAL, DENTAL AND

By Optometric Service

Abstract

Enter your initials and the date to certify that this report is true, complete and correct to the best of your knowledge Initials Date Click a YES or NO response to each question below before proceeding to Page 2 Responses may label certain pages of this report as “NOT REQUIRED

Topics: YES NO Are you an approved Accountable Health Plan in Arizona? Are you a Hospital, Medical, Dental or Optometric Service Corporation
Year: 2010
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