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Health Claim Form
To submit a manual claim, complete an insurance
Health Claim Form
, attach the original receipts and documents, and mail to the insurer. Remember to keep a copy of all original documents for your records.
The following information is required on the claim form:
Plan Number:
12356
Division Number:
Not Applicable Leave Blank
Plan Name:
SCHOOL
Employee Identification Number:
Your Student ID
Employee Name:
Your Name
Address:
Your Current Mailing Address
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