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Get File Z Business Office Public Business Office Forms Bcbs Texas Cob Questionnaire Pdf

/ / 1st Date of Dialysis for ESRD: / / Was ESRD started in a facility? Yes No Was ESRD started as Self Dialysis or Home Dialysis: Has a transplant been performed? Yes Yes No No If yes, please provide the date of the transplant. / / Section C If this does not apply, skip to Section D. COURT ORDER INFORMATION Is there a Court Order specifying a person(s) to maintain health coverage for any of your dependent(s)? No Yes List the name(s) of the depe.

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