Claim form must be submitted to Anthem NO LATER than Wed., December 31, [removed]Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. PLEASE PRIN - Anthem Blue Cross - Document - PDFSEARCH.IO

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	Claim form must be submitted to Anthem NO LATER than Wed., December 31, [removed]Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. PLEASE PRIN Add to Reading List Document Date: 2014-10-28 20:16:59 Open Document File Size: 517,38 KB Share Result on Facebook City Denver / / Company Wellpoint / Anthem / Medical Service Inc. / / Facility Rocky Mountain Hospital / / IndustryTerm insurance company 9c / / MedicalCondition flu / Health Fair flu / / Organization Rocky Mountain Hospital / Blue Cross and Blue Shield Association / / Position participating physician / / ProvinceOrState Colorado / / SocialTag Medicine Influenza vaccine Itemized deduction Influenza Public key certificate Blue Cross Blue Shield Association Anthem Health Taxation in the United States Vaccines

Claim form must be submitted to Anthem NO LATER than Wed., December 31, [removed]Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. PLEASE PRINAdd to Reading List