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Get Form 43a 2011-2024

Rts—Claim Form (NF–43A) (Page 1) kfd/A2/8400/31.doc (03/2011) 9.31 9.32 Group Administrator’s Manual Chapter 9–Forms and Reports—Claim Form (NF–43A) (Page 2) kfd/A2/8400/32.doc (03/2011) Group Administrator’s Manual 9.33 Completing a Capital BlueCross Claim Form—NF–43A The following information must be included with the claim: SECTION 1 1 Patient/Member Name – the first and last name of the patient who received the service. 2 ID Number number. 3 – the Subscr.

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