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IF YOU ELECT TO HAVE YOUR VISITS SUBMITTED TO YOUR INSURANCE COMPANY, PLEASE PROVIDE THE FOLLOWING INFORMATION: Name of Primary Insurance Company: (Please provide a copy of your insurance ID card)
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Submit the filled-out form by the specified method (e.g., mail, online, in-person).
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What is if you elect to?
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What is the purpose of if you elect to?
The purpose of electing to file or take action is to meet legal or regulatory requirements.
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Specific information related to the filing or action being taken must be reported.
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