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REQUEST FOR INDIVIDUAL CANCER DIAGNOSTIC BENEFITS INSTRUCTION TO INSURED 1. Complete STATEMENT OF INSURED 2. Please attach bill, receipt or evidence of diagnostic screening or preventative testing. Submitted evidence must include the name of the patient, type of test, provider, provider phone number and the date of service. 3. Be sure to include your account number or Social Security number on all documents. 4. Fax or mail completed form and attachments. STATEMENT OF INSURED 1) Patient s Na.

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