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Get Scripps Health Plan Corrected Claim 2016-2024

P.O. Box 2529 4S-300 La Jolla, CA 92038 Fax: 858-260-5852 Date Cover Sheet Prepared: Date Cover Sheet Prepared: _________________ Claim Identification Information Original Claim Number (from voucher): Subscriber’s Name (please print) Member ID Number Patient’s Name – if different from Subscriber Group Number Provider Office Information Name health care provider (please print) Tax ID Number Provider Office Contact: Telephone Number This claim is a corrected billing of a previous .

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