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Get Member Submitted Health Insurance Claim Form ... - Cheyney

Sing of your claim(s). Please do not highlight information or use red ink. Submit the claim and attach an itemized statement of services from the healthcare provider to the address provided on the back of your ID card. Cancelled checks, cash register receipts or personal itemizations are not acceptable. The itemized statement must include name of patient, date(s) of service, type of services performed, diagnosis and charge(s). You must use a separate claim form for each patient. All expenses for.

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