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Get And Sign Ca Statement Claim Form 2007-2021

First C. Each itemized bill B. Complete boxes 1 and 4 only C. Attach your Explanation of Medicare Benefits form and a copy of itemized services to this claim and send all to Blue Shield • Print or type • Fill in all items completely • Sign your name in the space provided •  oreign claims – any services rendered outside of F the United States or its territories must include the U.S. currency exchange rate or value and the translation for all billed...

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