Fillable ubhonline form

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1500 New York State Government Employees Health Insurance Program PICA 1. MEDICARE (Medicare #) HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 GROUP HEALTH PLAN FECA BLK LUNG (SSN) Y MEDICAID (Medicaid #) TRICARE CHAMPUS (Sponsor's SSN) CHAMPVA (Memberchip ID#) OTHER (ID) 1a. INSURED'S I.D. NUMBER PICA (For Program In Item 1) X (SSN or ID) MM DD 2. PATIENT'S NAME (Last...
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