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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...
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