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HEALTHCARE CLAIM FORM Reset Values You may fill out the form online and print it or print the form and fill it out by hand. EMPLOYEE STATEMENT Group Contract Number Certificate Number Employer Employee.

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  1. Open the document in our feature-rich online editing tool by clicking Get form.
  2. Fill in the requested boxes that are colored in yellow.
  3. Click the arrow with the inscription Next to move on from field to field.
  4. Go to the e-signature solution to put an electronic signature on the template.
  5. Put the relevant date.
  6. Check the whole template to be sure that you haven?t skipped anything.
  7. Hit Done and save the new template.

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