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OTHER COVERAGE QUESTIONNAIRE FOR GB HMO PLAN
RESPONSE
REQUIRED Post Office Box 98027
Baton Rouge, Louisiana 708989917An independent licensee of the Blue Cross and Blue Shield Association. Customer
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Blue Cross and Blue Shield are health insurance providers that offer a variety of coverage options.
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Information such as the patient's name, date of service, healthcare provider, diagnosis or reason for the visit, and the cost of the service or prescription must be reported on Blue Cross and Blue Shield forms.
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