Coverage Gap Discount Program

Coverage Gap Discount Program (CGDP)
Reconciliation System Reports

Contact Information
Name of Company:
Address:
City, State Zip:
Contact Person:
Email Address:
Phone Number:

Please provide in the box below the contract number(s) the person above is authorized to receive the CGDP Reconciliation System Reports for:* (Delimit by semicolon)

This document contains information of a proprietary nature. Information contained herein shall be kept confidential and divulged only to persons who, by nature of their duties, require access to such documentation.
Authorized Signer Information
I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and acknowledge same by signing below.
Name:
Email:
Phone Number: