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Get Indiana University Health Center Claim Form

3) School of Medicine (812801) Patient Name (if not the student) Student Name (as it appears on your ID card) ID Number (as it appears on your ID card) Address Patient Date of Birth / / City State Zip Telephone Number To expedite processing, please include the following PLEASE KEEP COPIES OF ALL DOCUMENTS FOR YOUR RECORDS. Is the Walk-out statement from the IU Health Center included? Yes No Are the detailed pharmacy receipts showing drug name, dosage, and cost included (if.

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