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Please submit your claim(s) with original bill(s) you received from the Provider or with the Provider's original signature on the attached bill(s). PATIENT'S NAME
 

Summary: Please submit your claim(s) with original bill(s) you received from the Provider or with the Provider's original signature on the attached bill(s).
PATIENT'S NAME
1. NAME OF SUBSCRIBER (Employee or Retiree)
GROUP NUMBER SUBSCRIBER IDENTIFICATION
STREET (AS SHOWN ON YOUR IDENTIFICATION CARD)
SEX PATIENT'S RELATIONSHIP TO SUBSCRIBER
MALE FEMALE 1. SELF 2. SPOUSE 3. CHILD
CITY 4. OTHER (Explain)
PATIENT'S DATE OF BIRTH
STATE ZIP CODE
MUST BE ACCURATE ______/______/______
THIS IS PART OF IDENTIFICATION Month Date Year
2. DESCRIBE THE ILLNESS OR INJURY REQUIRING TREATMENT ____________________________________________________________________
_____________________________________________________________________________________________________________________________
INJURY (DATE OF ACCIDENT) OR SHOW DATE: ______ /______ /______
3. WAS TREATMENT RESULT OF ILLNESS (DATE OF FIRST SYMPTOM) OR Month Day Year
(ENTER EITHER 1,2, OR 3) PREGNANCY (DATE OF CONCEPTION)
IF INJURY, WAS MOTOR VEHICLE INVOLVED? YES NO
4.
WAS ILLNESS OR INJURY WORK CONNECTED? YES NO NAME AND ADDRESS OF EMPLOYER

  

Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston

 

Collections: Biology and Medicine; Environmental Sciences and Ecology