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Chickasaw Nation Refill Center fax number
(580) 421-8701
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Prescription Program Enrollment
Used for: Submit enrollment forms and prescriptions for the Chickasaw Nation Refill Center Native & Non-Native Spouse Prescription Program
Fax destination details
- Department
- Prescription Program Enrollment
- Purpose
- Submit enrollment forms and prescriptions for the Chickasaw Nation Refill Center Native & Non-Native Spouse Prescription Program
- Form
- Form 02905NN — Chickasaw Nation Refill Center Native & Non-Native Spouse Prescription Program Enrollment Form
- Address
- 933 N Country Club Road, Ada, OK 74820
- Voice phone
- +1 580-421-8725
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Fax or mail the completed enrollment form and prescriptions to Chickasaw Nation Refill Center; include required documents (CDIB, tribal citizenship, prescription insurance card, marriage license) and sign the Acknowledgement of Receipt of Notice of Privacy Practices.
Official form instructions are published as a downloadable file on the organization's website.
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