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FLASHP GROUP ENROLLMENT FORM P. O. Box 22999 Rochester NY 14692 A nonprofit independent licensee of the BlueCross BlueShield Association DO NOT USE FOR INTERNAL PURPOSES ONLY HIOS ID EC Instructions on last page. In the event that a premium contribution is required of me I agree to pay the premium amounts applicable to the contract under which I am covered. I authorize my employer to deduct from my payroll such applicable amounts and to remit them to Excellus BlueCross BlueShield. If this...
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