HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA
Mail completed form to: Providers: GHI, P.O. Box 2832, New York, NY 10116-2832 Subscribers, Optical, Nursing Services: GHI, P.O. Box 3000, New York, NY 10116-3000 Mental Health and Substance Abuse: GHI, P.O. Box 2827, New York, NY 10116-2827 Durable Medical Equipment:...
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