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Get Blue Cross Extended Health Care Form

Or name of clinic) Date of each purchase or service or hospital admission and discharge dates (yyyy-mm-dd) Amount paid Provider of service or prescriber of medication Nature of illness or injury* See above 1 2 3 4 5 6 7 8 9 10 11 12 *Optional, but may result in refusal or delay of claim if not provided. Total claim (optional): $0.00 P acific Blue Cross, the registered trade-name of PBC Health Benefits Society, is an independent licensee of the Canadian Association of Blue Cross.

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