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*THIS FORM CAN ALSO BE USED FOR FILING CLAIMS FOR CAREFIRST BLUECHOICE OPT-OUT PLUS. 1. IDENTIFICATION NUMBER. 2. GROUP NUMBER OR ENROLLMENT CODE 3. PATIENTSRead more
THIS FORM IS TO BE USED TO SUBMIT A CLAIM FOR SERVICES RENDERED UNDER YOUR CAREFIRST. BLUECHOICE, INC. HEALTH PLAN. THE BLUECHOICE PROVIDER IS RESPONSIBLERead more
I request benefits for these expenses and DocHub that the above information is correct and that the foregoing expenses were incurred for the above.