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Get MI WF 12173 2018-2024

Cross and Blue Shield Association Complete this form and fax to: 1-866-411-2573 UAW Retiree Contracts fax to: 1-866-915-9811 Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete every field unless otherwise noted. Information must be legible. Place N/A if not applicable. Precertifications and Recertifications are not guarantee of payment. Incomplete or illegible submissions will be returned unprocessed. Disclaimer Statements .

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