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P.O. Box 1151 Little Rock, Arkansas 722031151 A SEPARATE CLAIM FORM MUST BE SUBMITTED FOR EACH PATIENT WHEN SENDING BILLS TO Usable Mutual Insurance Company 1. GROUP NUMBER & NAME 2. EMPLOYEE IS ID

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Box 1151 Little Rock refers to a specific box number where certain information needs to be reported.

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Entities or individuals required to report specific information as per regulations.

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