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Get AL CL-438 2014-2024

when your physician or other provider does not file a claim. Please print clearly with black ink or type. 1. Patient’s Name (only one Patient per form) Last First 2. Contract Number as shown on your I.D. Card Middle Initial 3. Group Number (as shown on I.D. Card) or Place of employment (include any letters, if applicable) 4. Patient’s Date of Birth Male 5. Patient’s Sex mm Female yyyy dd 6. Patient’s Relationship to Contract Holder Self Child Spouse Other (explain) 7. C.

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