Fillable bcbs of alabama form cl 94

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Point-of-Sale Participating Pharmacy An Independent Licensee of the Blue Cross and Blue Shield Association PRESCRIPTION DRUG CLAIM Use this form for filing Point-of-Sale Drugs from a Participating Pharmacy * * * IMPORTANT: Please Read The Instructions On The Back Of This Form * * * Section I. PATIENT/CONTRACT HOLDER INFORMATION Patient's Name (Last Name, First Name, Middle Initial) Patient's Birthdate MONTH DAY...
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