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Get BESTflex Plan Orthodontic Care Expense Receipt. Orthodontic Care Expense Receipt

Box 44347, Madison WI 53744-4347 800 346 2126, 608 831 8445, M - F 8:00 - 5:00 Central participantservices ebcflex.com Account Holder Information Last 4 Digits of Social Security or Identification Number (Required) Last Name First Name E-mail Address (we do not share your e-mail address) Employer Orthodontist Information and Charges Orthodontist Name Initial Fee Records Fee Monthly Installment Other Orthodontist s Tax ID# Patient s Name $ Dollar Amount Date of Payment (mm-dd-yyyy.

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