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Get Providence Health Plan Claims Address Form

Are subject to the specific conditions, duration limitations and all applicable maximums listed on your Vision Care Benefit Summary. Please attach any bill(s) for services received from a licensed eye care provider. Bill(s) must be suitable for insurance billing purposes and must include the following: Date of service Provider name, address and tax identification number Diagnosis and service codes and Amount charged for each service. Cash register or credit card receipts are n.

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  • subscribers
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  • summary
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