Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. P.O. Box 5747 Denver, CO[removed] - Flu Shot - Document - PDFSEARCH.IO

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	Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. P.O. Box 5747 Denver, CO[removed] Add to Reading List Document Date: 2012-01-06 11:09:09 Open Document File Size: 65,96 KB Share Result on Facebook City Denver / / Company Wellpoint / Anthem / Medical Service Inc. / / Facility Rocky Mountain Hospital / / IndustryTerm insurance company 9c / / MedicalCondition flu / / Organization Rocky Mountain Hospital / Blue Cross and Blue Shield Association / / Position participating physician / / ProvinceOrState Colorado / / SocialTag Influenza vaccine Vaccines Itemized deduction Blue Cross Blue Shield Association Public key certificate Influenza Anthem Taxation in the United States Health Medicine

Claim Form — Flu Shot Only One patient and one provider per claim form, please. See reverse side for claim filing instructions. P.O. Box 5747 Denver, CO[removed]Add to Reading List