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Dental Reimbursement Form Patient’s Name: Sex: M Male M Female Patient’s Birthdate: _____/_____/_____ MM DD YY Patient’s Relationship to Insured: M Self M Spouse M Child M Other Insured’s Name: Insured’s ID Number: Patient’s Address (No., Street): City: State: ZIP Code: Telephone: ( ) MM Date(s) of Service From: DD YY MM To: DD YY Description of Item or Service Amount Paid Procedure Code Provider’s Name: Provider’s Address (No., Street): City: State: ( ) ZIP Code: Telephone: Please submit a bill or receipt with the provider’s name and address. Include a complete description of services provided. Claims Address: BlueChoice HealthPlan Claims Department P.O. Box 6170 Columbia, SC 29260-6170 99835-3-2018 You have 3 months from the date of service to submit this form.

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  • Please submit a bill or receipt with the provider’s name and address.

    Dental Reimbursement Form

    Patient’s Name: Sex: M Male M Female

    Patient’s Birthdate: _____/_____/_____ MM DD YY

    Patient’s Relationship to Insured: M Self M Spouse M Child M Other

    Insured’s Name:

    Insured’s ID Number:

    Patient’s Address (No., Street):

    City: State:

    ZIP Code: Telephone: ( )

    MM

    Date(s) of Service From:

    DD YY MM To: DD YY Description of Item or Service

    Amount Paid

    Procedure Code

    Provider’s Name:

    Provider’s Address (No., Street):

    City: State:

    ( )ZIP Code: Telephone:

    Please submit a bill or receipt with the provider’s name and address. Include a complete description of services provided.

    Claims Address: BlueChoice HealthPlan

    Claims DepartmentP.O. Box 6170

    Columbia, SC 29260-6170

    99835-3-2018

    You have 3 months from the date of service to submit this form.

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    Rvs  3/13/2017   1   19199-‐3-‐2017  

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    Rvs  3/13/2017             2           19199-‐3-‐2017