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Get blue cross member appeal form 2021-2024

Ee ID card) ID number: Suffix: Address: / Group/policy number: City/State: ZIP code: Phone number: If you re appealing on the member s behalf, complete section B. If you re the member, continue to section C. Section B. Appealing on a member s behalf Do you have legal documents to act on the member s behalf? Yes, I am the legal guardian. Yes, I have Power of Attorney. If yes, attach legal documentation and continue to section C. No, I m not the legal guardian and I don.

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