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Get SAMBA Heath Insurance Claim Form

S of physician or supplier providing the service or supply Date service or supply was furnished Type of service or supply and the charge Diagnosis In addition: • A copy of the Explanation of Benefits from any primary payer (such as Medicare) must be sent with your claim. • Claims for rental or purchase of durable medical equipment, private duty nursing and physical, occupation and speech therapy require a written statement from the doctor specifying the medical necessity for the service or .

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