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Get I 500 Heatlh Insurance Claim Form

R s ID number is the subscriber number and the two-digit suffix listed next to the member s name on the ID card. This field accepts alpha and numeric characters. (Suffixes apply to New Blue products only) The patient s name should be entered as last name, first name, & middle initial. 2. Enter the patient s birth date and sex. The date of birth should be eight positions in the 3. MM/DD/YYYY format. Use one character (X) to indicate the sex of the patient. Enter the name of the insured. I.

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