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 This Form Can Be Used for All Medical, Dental, Vision and Prescription Claims 2017-2023

This Form Can Be Used for All Medical, Dental, Vision and Prescription Claims 2017-2023

Use a embs form 2017 template to make your document workflow more streamlined.

You have already paid for these services you should seek reimbursement directly from the provider. Com Website www. ebms. com provider is not submitting a claim on your behalf. Please refer to the previous page for instructions. City State Zip Phone Number Member I. D. Number PATIENT INFORMATION To be completed only if the patient is other than Employee Relationship to Employee Spouse Child Other Patient Mailing Address If different than above At the time the medical service was provided was...
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