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blue cross blue shield claim form

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P. O. Box 660044 Dallas Texas 75266-0044 Please Print or Type Claim Form to Pay Insured/Subscriber Each item on this form needs to be completed. Instructions for completion are listed on the reverse side. Authorization is hereby given to any Hospital Physician Dentist Provider Insurance Carrier or other entity to give Blue Cross and Blue Shield of Texas upon request any medical information which the Plans in their judgment deem necessary to the adjudication of this claim. Any person who...
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