bchp dental reimbursement form - bluechoicesc.com · asistans ak enfòmasyon nan lang ou pale a,...
TRANSCRIPT
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