All the information fields below must be completed. SCAN Member Name Member # or Date of Birth Name of Family Member/Friend Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Email Relative (indicate relationship) Friend Caregiver to SCAN Member Please send my family or friend literature in Spanish SCAN will not sell or share any provided names or personal information to other companies, and no personal medical information will be provided or shared through this program.