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Get Anthem Claim Form Pdf 2018-2024

Quick and accurate processing. See reverse side for complete instructions. Section 1: Patient information Last name First name Does the patient have other health insurance coverage? Yes No Name of other health insurance company Relation to subscriber Self Spouse Son Group no. M.I. Sex Daughter Male Employer name Date of birth (MM/DD/YYYY) Female Policy no. Section 2: Subscriber information (on Anthem Blue Cross ID card) Identification no. (include prefix) Group no.

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