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35. Remarks Registered Marks of the Blue Cross and Blue Shield Association.
 

Summary: 35. Remarks
Registered Marks of the Blue Cross and Blue Shield Association.
2007 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 26-1025 (8/07)
Dental Claim Form
Pay Subscriber
BCS Pay Subscriber
HEADER INFORMATION
1.Type of Transaction (Mark all applicable boxes)
Statement of Actual Services Request for Predetermination/Preauthorization
EPSDT/Title XIX
2. Predetermination/Preauthorization Number
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name,Address, City, State, Zip Code
OTHER COVERAGE
4. Other Dental or Medical Coverage? No (Skip 5-11) Yes (Complete 5-11)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
11. Other Insurance Company/Dental Benefit Plan Name,Address, City, State, Zip Code
6. Date of Birth (MM/DD/CCYY) 7. Gender
M F
8. Policyholder/Subscriber ID (SSN or ID#)

  

Source: Aalberts, Daniel P. - Department of Physics, Williams College

 

Collections: Physics