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Get Anthem Medical Claim Form 2011

accurate processing. SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS. Section 1.  PATIENT INFORMATION Last name M.I. Relation to subscriber No Self  Name of other health insurance company Save and Print First name Does the patient have other health insurance coverage? Yes  Reset Form Spouse  Group no. Son  Employer name Section 2.  SUBSCRIBER INFORMATION (on Anthem Blue Cross ID card) Identification no. Group no. Last name First name Street address (please include apt. .

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