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C. P. 3950 L is (EU BEC) G6V 8C6 Fax: 418-838-2134 1-877-838-2134 GROUP INSURANCE HEALTH CLAIMS PRIOR AUTHORIZATION REQUEST FORTE (TRIPARTITE) Please read the instructions on the back of this form
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What is members last name and?
Members last name and is the surname of an individual.
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Anyone who is filling out a form or document that requires the last name of a member.
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The purpose of including members last name is to accurately identify the individual.
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Only the last name of the member needs to be reported.
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