Form 4f1-18058-F - Retail Prescription Drug Claim Form (Soanish) Page 3
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4Por la presente, doy autorización a cualquier proveedor que haya participado de cualquier manera en mi
cuidado, a facilitar al seguro Blue Cross Blue Shield cualquier información médica que se considere
necesaria para adjudicar este reclamo.
FIRMA DEL ABONADO
FECHA
Instrucciones
1. Se requiere un formulario de reclamos separado para cada paciente y para cada farmacia. Cada
formulario de reclamos se debe firmar por el abonado y/o el paciente.
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Parent category: Business