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P.O. Box 5747 Denver, CO 802175747 ONE PATIENT AND ONE PROVIDER PER CLAIM FORM SEE REVERSE SIDE FOR CLAIM FILING INSTRUCTIONS 1. SUBSCRIBER NUMBER 5. PATIENT SEX I MALE 2. GROUP NUMBER Subscriber
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Start by writing the recipient's name, company (if applicable), and title (if known) on the first line. If you are unsure about the title, leaving it blank is acceptable.
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