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Get HTH SUNY ICF 001 2010-2024

The claim form, signing the back of the form and attaching all required documentation will help us to process your claim quickly and accurately. SEE REVERSE SIDE FOR REQUIRED AUTHORIZATION SIGNATURE AND INSTRUCTIONS MEDICAL INFORMATION NAME: PATIENT INFORMATION Family Name Given Name INSURED INFORMATION (on ID Card) Certificate Number: Group Name: State University of New York (SUNY) NAME: Birth Date MM DD YY Gender Family Name Given Name Relationship to Insured member Reimbursement Maili.

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