home *** CD-ROM | disk | FTP | other *** search
/ Power Bytes: Money & Finance / PowerBytes Money and Finance CD-ROM 01 / PowerBytes Money and Finance CD-ROM 01.iso / Graphics / *MacDraw Art / abc medical (.png) < prev    next >
MacDraw  |  1995-01-01  |  7.0 KB  |  816x1056  |  8-bit (256 colors)  |  [DRWG/MDRW]
   ocr: ABC MEDICAL SERVICES MEMBER CLAIM FORM INSTRUCTIONS: MAIL THIS FORM WHEN COMPLETED 1. Complete one Member Claim Form for each patient. TO: ABC Medical Services P.O. Box 50002 2.Attach an itemized bill containing patient's name, provider Princeton, Ca. 95159 of: amount service's charged IRS # for name each and supply address, or: service type for date each and Attn: Claims Dept. member claim. PATIENTS NAME Date of Birth SEX EMPLOYEE: RELATIONSHIP TO LAST FIRST MIDDLE Mo. IDay lYr MALE FEMALE SELF SPOUSE CHILD OTHER OCCUPATION EMPLOYER (HOSP) PARTA (MED) PART B COVERED BY MEDICARE? YES NO DATE I ...