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HEALTH CARE CLAIM FORM P.O. Box 64030 The Woodlands, TX 773874030 Fax: 18882119900FIRST NAMELESS NAMEEMPLOYEE ID (OPTIONAL)M.I.ZIP CODEINE 1 DATE OF SERVICE (MM/DD/CITY)SERVICE PROVIDERREQUESTED OUTPATIENT

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Box 64030 is a specific section on a form or document where certain information needs to be reported.

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The purpose of box 64030 is to collect specific information deemed necessary for reporting or compliance purposes.

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