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Get Boon-Chapman Health Care Reimbursement Request Form

RM A. INSTRUCTIONS • • • • • • COMPLETE ALL SECTIONS (B,C, AND D) FOR CHARGES TO BE CONSIDERED FOR REIMBURSEMENT. IF EXPENSE IS COVERED BY INSURANCE, SUBMIT TO APPROPRIATE CARRIER. ATTACH EXPLANATION OF BENEFITS (EOB) FROM THE INSURANCE CARRIER OR CO-PAY RECEIPTS. IF YOU ARE SUBMITTING AN ITEMIZED BILL ONLY, INDICATE WHY THIS BILL HAS NOT BEEN PAID BY YOUR INSURANCE PLAN ITEMIZED BILLS SHOULD INCLUDE THE FOLLOWING: * PROVIDER NAME & ADDRESS * PATIENT NAME * ITEMIZED CHARGES * DATE.

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