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165 Court Street Rochester NY 14647 Customer Submitted Dental Claim Form A nonprofit independent licensee of the BlueCross BlueShield Association Mail Completed Forms To Excellus BlueCross BlueShield PO Box 22999 HEADER INFORMATION POLICYHOLDER/SUBSCRIBER INFORMATION For Insurance Company Named in 3 1. Type of Transaction Mark all applicable boxes Statement of Actual Services Request for Predetermination/Preauthorization EPSDT/Title XIX G 12. Policyholder/Subscriber Name Last First Middle...
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PO Box 22999 Rochester is a postal box located in Rochester, which is used for receiving mail and packages.
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Anyone who wishes to receive mail or packages at PO Box 22999 Rochester is required to file for it.
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