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Get VA Anthem Form 151 2002

Claim Information/ Adjustment Request 151 Form Please Mail Form To P. O. Box 27401 Richmond VA 23279-7401 Provider Please complete all sections of this form to assist us when researching your inquiry. Insured s ID Number Claim Filed Paper as shown on Patient s ID card Claim Type Professional Patient s Name Electronic Patient s Account Number Facility Date Sent Dental Other Insurance if applicable to inquiry Claim Number Charge Please Return To Insurance Company Name Telephone Number Policy Number Effective Date Name of Referring Physician Provider s Name and Address Certification Number Dates of Service Home Other Inpatient Hospital Office Place of Treatment PLEASE DESCRIBE Outpatient Hospital Group Name or Number Reason Additional Information Attached Other Explain Overpayment Underpayment Onset Date // Check Appropriate Box Consult Date // LMP Accident Illness first symptom 837 Attachment Control Number Briefly Describe Claim Issue and Action Required For Internal Use Only Reply Date Name Inquiry Number 710039 12/2002 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia Inc. Independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association.. Claim Information/ Adjustment Request 151 Form Please Mail Form To P. O. Box 27401 Richmond VA 23279-7401 Provider Please complete all sections of this form to assist us when researching your inquiry. Insured s ID Number Claim Filed Paper as shown on Patient s ID card Claim Type Professional Patient s Name Electronic Patient s Account Number Facility Date Sent Dental Other Insurance if applicable to inquiry Claim Number Charge Please Return To Insurance Company Name Telephone Number Policy Number Effective Date Name of Referring Physician Provider s Name and Address Certification Number Dates of Service Home Other Inpatient Hospital Office Place of Treatment PLEASE DESCRIBE Outpatient Hospital Group Name or Number Reason Additional Information Attached Other Explain Overpayment Underpayment Onset Date // Check Appropriate Box Consult Date // LMP Accident Illness first symptom 837 Attachment Control Number Briefly Describe Claim Issue and Action Required For Internal Use Only Reply Date Name Inquiry Number 710039 12/2002 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia Inc* Independent licensees of the Blue Cross and Blue Shield Association* Registered marks Blue Cross and Blue Shield Association*. .

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