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Get CareFirst CUT9308-1P 2014-2024

Provider Information Completed by Provider Please print. First Name MI Please print. Provider Name Member ID Number (found on ID card) Provider ID Number Provider Phone Number Gender (Check one) Date of Birth / (mm/dd/yyyy) / Male Female Group Number (found on ID card) Effective Date of Coverage (verify in CareFirst Direct or call 1-800-676-BLUE outside of MD, DC, N. VA) Section II: Health Measures Completed by Provider 1. Tobacco Use (required for ages 18 and older) Re.

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