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Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services EPSDT/ Title XIX 2. Predetermination / Preauthorization Number Request for Predetermination / Preauthorization Guardian Group Dental Claims PO Box 2459 Spokane WA 99210-2459 POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3) 12. Policyholder/Subscriber Name (Last, First, Middle...
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