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Get New Jersey Health Insurance Claim 2021-2024

ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING: Check that each itemized bill is legible and contains ALL of the following information: NAME & ADDRESS of person or institution rendering the service or supplying the item Health Care Professional Federal Tax Identification Number (Required) Health Care Professional NPI Number PATIENT S FULL NAME TYPE of service rendered/produced or item supplied DATE each service rendere.

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