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Get Blue Cross Blue Shield Illinois 2015 July Form

Authorization agreement. o Verify with your financial institution that they can accept automated electronic withdrawals. o Return this authorization and a blank check marked VOID for the account from which funds are to be withdrawn to: Blue MedicareRx (PDP), PO Box 3897, Scranton, PA 18505. Your payments will be deducted approximately the 4th of each month. AGREEMENT I, as account holder, hereby authorize HCSC Insurance Services Company (HISC) to initiate withdrawals on a monthly basis from my.

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