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CLAIM FORM — GROUP MEDICAL Mail Completed Form To: BEST Life and Health Insurance Company P.O. Box 890 • Meridian, ID • [removed]0088 | Fax[removed]
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Document Date: 2014-05-29 13:26:58

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City

Washington / Employer / /

Company

Health Insurance Company / /

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IndustryTerm

insurance fraud / dental services / insurance policy containing / federal law / state law / insurance / insurance benefits / nuclear imaging / insurance proceeds / benefits or services / fraudulent insurance act / /

Organization

Department of Regulatory Agencies / Health Maintenance Organization / Colorado Division of Insurance / Medicare / /

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Position

undersigned Physician / physician / authorized representative / /

ProvinceOrState

Texas / Tennessee / Kentucky / New Mexico / Ohio / Virginia / Alabama / Alaska / District of Columbia / Pennsylvania / Rhode Island / Maryland / Oklahoma / Indiana / Louisiana / Oregon / Florida / Hawaii / California / Arizona / Idaho / Colorado / Arkansas / /

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