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Get and Sign What is Printable Claim Format
Submitting your claims for reimbursement.
Please list one patient and service per line. The type of service field indicates what type of service was provided, i.e., Medical (Med), Dental
(Den), Vision (Vis), Orthodontia (Ort), or Prescription (RX).
In accordance with IRS regulations, the actual date which services were rendered is required. Many providers and insurance bills have a
separate billing date, please don’t mistake this billing date for the date services were...
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