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Efit for which you have paid out of pocket. Refer to the following guidelines when submitting your request: Tape your original receipts in the boxes marked for receipts. Cash register receipts do A not provide enough information and are not acceptable. Complete one form per patient. A Keep copies of receipts for your records. Original copies will not be returned. A If you have other insurance that is primary over our coverage, an Explanation of Benefits A (EOB) from the primary insurance must.

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