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Get International Claim Form - The Wels Benefit Plans Office!

Side of this form before completing. Please type or print. Send completed form to: B lueCard Worldwide Service Center or claims bluecardworldwide.com P.O. Box 261630 Miami, FL 33126 USA 1. Patient Information 1A. Alpha prefix Identification number Copy this from your Blue Cross Blue Shield identification card. (First, middle initial, last) 1C. Patient s date of birth MM/DD/YYYY 1B. Patient s name 1E. Name of subscriber / (First, middle initial, last) / 1F. Subscri.

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