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PLACE STAMP HERE PreferredOne Administrative Services P. O. Box 59212 Minneapolis MN 55459-0212 EMPLOYER GROUP NUMBER EMPLOYEE S NAME Last First Middle Initial SOCIAL SECURITY NUMBER EMPLOYEE S ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER PATIENT S NAME DATE OF BIRTH SELF SPOUSE CHILD ARE YOU YOUR SPOUSE AND/OR DEPENDENTS COVERED UNDER ANY OTHER HEALTHCARE POLICY AT THE TIME THE ENCLOSED CLAIM WAS INCURRED YES NO IF YES LIST NAME OF CARRIER AND MEMBERS COVERED WHAT IS THE NAME AND ADDRESS OF THE COMPANY AND THE POLICY NUMBER NATURE OF ILLNESS OR INJURY IF ACCIDENT STATE WHEN WHERE AND HOW IT OCCURRED If the claim is on a dependent who is over 19 years old and a full-time student identify name and address of school PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED DATE PLEASE SEND THE ORIGINAL BILLS*. NOT PHOTOCOPIES* If any bills have been paid please mark them PAID. Important Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED DATE PLEASE SEND THE ORIGINAL BILLS*. NOT PHOTOCOPIES* If any bills have been paid please mark them PAID. SIGNED DATE PLEASE SEND THE ORIGINAL BILLS*. NOT PHOTOCOPIES* If any bills have been paid please mark them PAID. Important Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. INSURED S OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED DATE PLEASE SEND THE ORIGINAL BILLS*. NOT PHOTOCOPIES* If any bills have been paid please mark them PAID. Important Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

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Keywords relevant to Preferred One Claim Form

  • dependents
  • incurred
  • healthcare
  • knowingly
  • misleading
  • Penalties
  • enclosed
  • Minneapolis
  • administrative
  • spouse
  • Supplier
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