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Get Canada GSC Claim Form for Medical Devices 2014-2024

E available at www.greenshield.ca. PROVIDER GREEN SHIELD PROVIDER NO. PATIENT PROVIDER PHONE NO. ( GREEN SHIELD I.D. # DEP # COMPANY NAME ) PROVIDER NAME SURNAME FIRST NAME BIRTH DATE / YY ADDRESS / MM DD ADDRESS CITY PROVINCE POSTAL CODE CITY PROVINCE POSTAL CODE I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. I understand that this information may be seen by the cardholder. By signing this clai.

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