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Get Canada Long-term Care Facility Claim Form 2015-2024

, in order to confirm the accuracy of the submitted claim(s) information. In the event of suspected fraudulent activity pertaining to claims submitted on behalf of myself and/or my dependents, I acknowledge and agree to the disclosure of this information to relevant parties, such as the Plan Sponsor, regulatory and law enforcement agencies. The cost, if any, of obtaining this information is at the expense of the patient/plan member. LONG TERM CARE FACILITY EN(Rev. 2015-01) All claims must be .

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