Direct Reimbursement Claim Form - Florida Blue Page 2
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2FRAUD STATEMENT
Any person who knowingly and with intent to defraud and deceive any insurance company submits
an insurance application or statement of claim containing any false, incomplete or misleading
information may be subject to civil or criminal penalties, depending upon state law.
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement
of claim or an insurance application containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
82753-0514
CL00142
5/13/14
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