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Get EMBS Member Claim Submission Form 2017-2024

Your behalf. Out-of-Network claims can be submitted by the provider if the provider is willing and able to file on your behalf. 2. You must submit an itemized bill for your claim to be processed. Receipts, balance due statements and cancelled checks are not acceptable replacements for the itemized bill. 3. Itemized Bills Must Include: Employee Name Patient Name Type of Service (CPT Code) Provider Name Provider Address Provider Tax ID Number Date of Service Diagnosis Code Charge for Service 4.

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