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Get Chlic Notice Of Claim 2011-2024

Ce Company") P.O. Box 2568 Jacksonville, Florida 32203-2568 Phone: 1.800.888.5256 FOR OFFICE USE ONLY PLAN EFF. DATE 30/20 PLAN 365+ PLAN PPP PLAN SIS PLAN PTD Instructions: 1. Complete this "Notice of Claim" form by answering all questions and signing at the bottom of the form. 2. Mail the completed claim form to the address shown above, along with your ITEMIZED BILL (UB04). Please remember to: • • Submit a separate claim form and Facility Bill for each Hospital Stay or Out Patient.

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