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Get and Sign Employee FormsResources the City of Stafford

Get and Sign Employee FormsResources the City of Stafford

Use a national form dental claim template to make your document workflow more streamlined.

Follow printed in boldface. I.e. Self not checked in Item 18 19. Check FTS if patient is a dependent and full-time student PTS if a part-time student. Relationship to Policyholder/Subscriber in 12 above 19. Student Status h Self h Spouse h Dependent Child h Other h FTS h PTS 20. Predetermination/Preauthorization Number POLICYHOLDER/ SUBSCRIBER INFORMATION INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION 12. Company/Plan Name Address City State ZIP 13. Date of Birth MM/DD/CCYY 14. Gender hM hF...
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