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The Heart Attack Stroke Prevention Center Breaking ground with the Bale/Doneen Method Universal Insurance Claim Form Please send reimbursement to the patient listed below. This form replaces HCFA. The patient has paid provider for services. Patient instruction Submit a copy of your insurance card and a copy of your bill slip along with this universal insurance form to your insurance company. Secondary insurance company Secondary policy holder s birthday month/day/year Provider signature is...
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