Get Bankers Independent Caregiver Itemized Bill & Daily Visit Note Form 2010
To our website: bankers.com (9/10) Claimant or Legal Representative Signature: ______________________________________________________________________________________________________ Date: ________/ ________/ ________ Fraud Notice: Any person who, with an intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to criminal and civil penalt.
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