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In the PLEASE SIGN AND DATE AUTHORIZATION, Patient Parent or Subscriber, Date, AUTHORIZATION TO PAY BENEFITS TO, Insured Person Signature, Date, TO BE COMPLETED BY AMERICAN STATES, Eligibility and status approved by, Claims Administrator, Date, COMPLETE AND R, ETURN, THIS FORM PROMPTLY, and Central United Life Insurance field, note your information.
Indicate the important data in PART B TO BE COMPLETED BY PROVIDER, Mailing Address, City State Zip, Soc Sec No or EIN, License No, Phone No, Is exam required as condition of, If Yes to or above give brief, EXAMINATION, Description, Date Code Fee Plan Allowance, Patient Responsibility, HAVE GLASSES BEEN PRESCRIBED Yes, Date Code Fee Plan Allowance, and Patient Responsibility segment.
Indicate the rights and obligations of the sides within the space FRAMES Mfg Name Style HAVE, Prescription Hard or Soft Daily, Gas Permeable or Extended Wear, BIFOCAL CCL Bifocal Style, RAM Crescent Curve Top One Piece, Manufacturer Style The services, I hereby certify that the services, Provider Signature PROVIDER, and Date.
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