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M Post Office Box 5433 Spokane, WA 99205 PARTICIPANT INFORMATION - PLEASE FILL OUT ONE CLAIM FORM FOR EACH INDIVIDUAL - Name: Account ID Number or SSN: Date of Birth: Mailing Address: Check here if new address City: State: Zip: Phone: Patient Name (person incurring expense): Relationship: Self Spouse Dependent Other: SECTION A: REIMBURSEMENT REQUEST Date of Service Provider Name Expense Description Amount SECTION B: INSURANCE PREMIUM REIMBURSEMENT REQUEST Name of Insurance Co.

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