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  • Medavie Blue Cross Claim Form

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ART 1 DENTIST P A T I E N T FIRST NAME LAST NAME ADDRESS APT. CITY PROV. POSTAL CODE D E N T I S T Canadian Life and Health Insurance Association Inc. 185 THE WEST MALL SUITE 1200 ETOBICOKE ON M9C 5P1 INQUIRIES: 1-800-355-9133 SPEC PATIENT'S OFFICE ACCOUNT NO. I HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIM TO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLY TO HIM/HER. PHONE NO. SIGNATURE OF SUBSCRIBER FOR DENTIST'S USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURE.

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I am writing this letter in regards with the insurance claim for my car. My car insurance policy number is _______________. The details of the car accident are mentioned below: On (incidence date) ___________, I parked my car in front of my office, in the parking area.

How to File a Claim Call Preferred Long-Term Care (LTC) Customer Service (1-888-331-4188) to complete the Claims Intake Form over the telephone. Blue Cross and Blue Shield of Alabama will send you a Claims Packet to be completed and returned to us.

We can appreciate that when you make a claim, you're paying out of pocket and you want your money back as soon as possible. Our updated process ensures that when you submit a claim before 5 p.m. MT, payment will go out to your bank account the next business day, provided there are no delays by your bank.

Visit BlueCrossNC.com/Claims for prescription drug, dental and international claim forms, or call the toll-free number on your ID card. Important Notes When Completing the Claim Form: Type or use blue or black ink to complete. Complete a separate claim form for each covered family member.

Blue Cross NC's Customer Service representatives are available to answer calls at 1-877-258-3334, Monday through Friday from 8:00 a.m. to 7:00 p.m. For greater speed and convenience, visit Blue Connect.

NC BCBS (Payer ID 61473) NC BCBS FEP (Payer ID 61472)

If you need to submit a claim, please mail it in time to be received by Blue Cross NC within 18 months after the service was provided. Claims not received within 18 months from the date the service was provided will not be covered, except in the absence of legal capacity of the member.

Any claim that can be submitted on paper can be submitted electronically. If you need more information on how to submit claims electronically call 1-800-AVAILITY (282-4548) or log in to Availity .

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232