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Benefits will not be paid for services or treatment rendered by any person who is a. employed or retained by the Policyholder b. This assignment of Benefits will be honored. If your Provider does not bill on a HICFA or UB92 Form You will need to sign the authorization to pay Benefits to the Provider on the front of this form. If your family insurance carrier is an HMO organization CONTACT YOUR HMO PHYSICIAN AT ONCE. FAILURE TO DO SO MAY RESULT IN THE CLAIM BEING DENIED OR A SUBSTANTIALLY...
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