Fillable MEMBER CLAIM FORM PLEASE REFER TO THE INSTRUCTION ... - icgov

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Save PO Box 9291 Des Moines, Iowa 50306-9291 Clear Form MEMBER CLAIM FORM An Independent Licensee of the Blue Cross and Blue Shield Association A SEPARATE CLAIM FORM MUST BE SUBMITTED FOR EACH PATIENT WHEN SENDING BILLS TO WELLMARK BLUE CROSS AND BLUE SHIELD OF IOWA PLEASE REFER TO THE INSTRUCTION ON THE BACK OF THIS FORM WHEN FILING YOUR CLAIMS. Identification Number (as indicated on your identification card...
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