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Get Anthem COVA/TLC 2012-2024

Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to Blue View Vision within one (1) year from the original date of service at the out-of-network provider’s office. 1. When visiting an out-of-network provider, you are responsible for payment of services and/or materials at the time of service. Blue View Vision will reimburse you for authorized services according to your plan design. Check will be sent directly .

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