MONTH (beta) 6d. MONTH (gamma) 6e. CASH REFUND (EUROPE). 6f. CASH REFUND (CHINA). 6g. INCOME TAX (EUROPE). 6h. INCOME TAX (CHINA). 6i. TOTAL FRAUD OFFENSE. 6j. TOTAL FRAUD OFFENSE. 6k. TOTAL FRAUD OFFENSE. 6l. TOTAL FRAUD OFFENSE. 6 m. TOTAL FRAUD OFFENSE. 6n. TOTAL FRAUD OFFENSE. 6o. TOTAL FRAUD OFFENSE. 6p. TOTAL FRAUD OFFENSE. 6q. TOTAL FRAUD OFFENSE. 6r. TOTAL FRAUD OFFENSE. 6s. TOTAL FRAUD OFFENSE. 6t. TOTAL FRAUD OFFENSE. 6u. TOTAL FRAUD OFFENSE. 6v. PART B 1. PHYSICIAN'S ADDRESS. 2. OTHER INDIVIDUAL'S NAME (FIRST) 3. MANDATORY NUMBER SENDER'S LAST NAME. 4. PHYSICIAN'S ADDRESS INSTRUCTIONS. 5. INFORMATION ABOUT PAYMENT 6. PRECONDITION WHEN NOT PAID 7. CONTACT INFORMATION ABOUT HEALTH COVERAGE 8. ADDITIONAL INSURANCE INFORMATION TO BE SENT TO HEALTH PLAN 9. ADDITIONAL INSURANCE INFORMATION TO BE SENT TO HEALTH PLAN 10. INSURANCE INFORMATION IN CASE OF INCONVENIENCE TO HEALTH PLAN 11. INITIAL PLAN COVERAGE FOR HEALTH CARRIER 12. INDIVIDUAL'S PHYSICIAN'S ADDRESS INFORMATION 13. INDIVIDUAL'S ADDRESS INSTRUCTIONS 14. INDIVIDUAL'S PAYMENT INFORMATION 15. INDIVIDUAL'S PHYSICIAN'S ADDRESS INFORMATION 16. INDIVIDUAL'S ADDRESS INSTRUCTIONS 17. INDIVIDUAL'S PAYMENT INFORMATION 18. FRAUD OFFENSE INFORMATION 19. FRAUD OFFENSE INFORMATION FOR HOUSING AND INDUSTRIAL RENTAL 21. FRAUD ATTENDANCE INFORMATION FOR PUBLIC SERVICES PROVIDED BY THE NATION 22.
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C Health Account Services P. O. Box 942715 Sacramento CA 94229 -2715 888 CalPERS or 888-225-7377 TTY 877 249-7442 FAX 800 959-6545 Direct Payment Authorization Form HBD-21 1. It is the employee s responsibility to provide the carrier with a copy of the Direct Payment Authorization form HBD-21 and all payments by the established due dates.
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