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Hlth 2814 2013
Specifically to obtain medical care,
you must receive prior approval for payment of insured services
– see Section D, Elective Services on page 4
• This form must be completed and signed by the patient or their
legal guardian
• Retain copies of bills or receipts for your records
SECTION A – PATIENT INFORMATION
PATIENT LAST NAME
PATIENT FIRST NAME(S)
BIRTHDATE (DD / MM / YYYY)
GENDER
PERSONAL HEALTH NUMBER (PHN)
HOME PHONE NUMBER
MALE
WORK PHONE NUMBER
FEMALE
MAILING...
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