Related links
Pharmacy Services Prescriptive Drug Claim Form
This form is to be used to seek reimbursement from ConnectiCare for prescription drug costs you paid above the cost-share amounts outlined under your plans
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SUBSCRIBERS STATEMENT OF CLAIM
SUBSCRIBERS STATEMENT OF CLAIM. This form is to be used ONLY when the Provider of Service does not submit your claim directly to Blue Shield. Check with the
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HEALTH INSURANCE CLAIM FORM
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty
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