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Description of CALIFORNIA
SUBSCRIBER S STATEMENT OF CLAIM IMPORTANT INSTRUCTIONS This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield. Check with the Provider to be sure no claim has been submitted* Duplicate claims will not only be rejected but may delay payment of the original claim* EXCEPTIONS USE A SEPARATE FORM FOR A. EACH MEMBER OF THE FAMILY PRIMARY MEDICARE COVERAGE A....
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