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MEDICAL CLAIM FORM CLAIM ASSISTANCE 1-800-427-9308 MCA ADMINISTRATORS INC. 1. COMPLETE THIS FORM 2. B. forward the E.O. B. along with any unpaid itemized bills and a completed claim form to the claim administrator MCA Administrators Inc. formerly DGA for processing paid receipts and/or balance due statements are not accepted. If you do not have other valid and collectible insurance Auto Employer Provided Family Insurance or Self-Provided complete.

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