Affidavit For Medical Reimbursement
Category:
State:
Mississippi
Control #:
MS-MEDAF-WC
Format:
PDF
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Medical Records Affidavit
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IMPORTANT - You must complete the attached In-Home Attendant Worksheet (page 5) to claim in-home attendant expenses. Reimbursement is applied to and subject to any applicable annual benefits maximum.See your plan documents or contact Cigna for complete program details. FAX: Fax the complete form to .