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Get Premera Blue Cross Prescription Reimbursement Claims Fax Number Form

Number Rx Group Number BCWAPDP Member Name (First, Last) Street Address City State Zip Patient Information Patient Name (First, Last) Patient Date of Birth (Month/Day/Year) Gender Relation to Plan Subscriber Female 1 Self Male 2 Spouse/Domestic Partner 3 Dependent Claim Receipts Tape claim receipts or itemized bills on the back. Do not staple! Check the appropriate box if any of the receipts are for a medication that: Is a compound prescription.* Make sure your pharmacis.

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