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Otherwise in writing. In which currency was the treatment originally billed? Member s and patient s details Patient s name and address Telephone No: Fax No: Mobile No: Address to which payment should be sent if different from above: G. Medical providers details: Name of medical provider: Telephone no: Address of medical provider: Fax no: H. If you are claiming for treatment received outside your area of cover, please answer the following questions: (a) Country where the treatment t.

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