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accept assignment ACCIDENT allowable charge Area Code beneficiary Blue Cross Blue Shield plans CHAMPUS and CHAMPVA cIaim claim process coinsurance compIete item 9 coverage covered Cross and Blue Current Procedural Terminology DATE OF BIRTH DD YY deductible diagnostic code disease eligible employees EMPLOYER'S NAME EPSDT explanation of benefits federal fees government program GROUP NUMBER Guided Practice HCPCS Health Insurance Claim health maintenance organization ID NUMBER illness or injury insurance carrier insurance claim form insurance company INSURANCE PLAN NAME INSURED'S NAME Last Leave blank Medicaid medical insurance specialist medical office medical services Medicare Medigap MiddIe InitiaI modifiers NAME Last Name NAME OR PROGRAM NAME OR SCHOOL patient information form patient's chart PHYSICIAN OR SUPPLIER primary diagnosis procedure code PROGRAM NAME provider records REFERRING PHYSICIAN reimbursement SCHOOL NAME SIGNATURE I authorize surance TELEPHONE INCLUDE AREA treatment workers YY MM DD ZIP CODE