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Get Statement Of Claim For Members And Dependents

TRUCTIONS For optical, and hearing aid benefits claimed, have attending physician complete the appropriate section on reverse side and/or attach itemized bills. For prescription expense balances only after primary insurance carrier payment, please attached itemized pharmacy receipts and other carrier payment information. Submit all other prescription expenses directly to the current prescription card company using their Direct Member Reimbursement Form which can be found on the MEBA webs.

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