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Get Conect Your Care Manual Claim Form

On online or print out the Cover Form to fax your receipts. Manual Claim Form If you cannot submit a claim online, you may complete and submit this form. Do not use this form if you already submitted this claim online or used your payment card. Complete all entries on this submission form. Please print or type. Sign and date this form. Fax or mail it, along with the required documentation, to the claims department. If you have any questions, please contact Customer Service 87.

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