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Havioral Health page 2 web-DENIS resources web-DENIS Billing page 3 Blue Cross Blue Shield of Michigan STATUS CLAIM REVIEW FORM LAST NAME OF INSURED/SUBSCRIBER GROUP NO. FIRST NAME PHYSICIAN OR PROVIDER NAME, ADDRESS, ZIP CODE SERVICE CODE INSURED'S/SUBSCRIBER IDENTIFYING NO. (INCLUDE ANY LETTERS) PROVIDER CODE/NPI A. B. BC/BS F.E.P. COMP. O/S TELEPHONE NUMBER NPI P.O.T.A. REJ. CORR. ORIGINAL FORM WAS PAY PROVIDER COMP NPR YES 1. PATIENT'S LAST NAME 2. MID. 3. FIRST N.

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