Fillable 5% Max Claim Form - Utah Department of Health - health utah

Description
5% Max Claim Form CHIP: (801) 538-9004 or 1-866-772-1261 My out-of-pocket maximum is: Parent/Guardian Name: Case Number: Health Insurance Company: Use this form to keep track of your children's medical services to show you have reached your out-of-pocket maximum. Once this is met, submit this form to the Children's Health Insurance Program. Complete one line for each copayment or coinsurance yo u incur
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