Various Fillable Forms
Customer Submitted Dental Claim Form 165 Court Street Rochester NY 14647 A nonprofit independent licensee of the BlueCross BlueShield Association Mail Completed Forms To: Excellus BlueCross BlueShield PO Box 22999 Rochester, NY 14692 HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes) Statement of Actual Services Request for Predetermination/Preauthorization EPSDT/Title XIX POLICYHOLDER/SUBSCRIBER INFORMATION (For Insurance Company Named in #3) 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code G G G 2 MoreDental Claim Form. A nonprofit independent ... (Last, First, Middle Initial, Suffix). 6 . Date of Birth (MM/DD/CCYY) ... Mail Completed Forms To: Excellus BlueCross ... Less
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