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By submitting this Health Services Claim (claim) for processing and payment by Alberta Blue ... Claim information* (please follow instructions, see reverse).

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Start by reading the instructions provided on the reverse side.

03

Begin by filling in the required personal information, such as your name, address, and contact details.

04

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The reverse side of the form will provide details about the individuals or entities that require the filled-out information.

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Refer to the information provided on the reverse side to determine the exact purpose and intended recipient of the form.

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Please see reverse for specific instructions or information on the back side of the document.

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