Insurance Claim Log Detailed

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Insurance Claim Log
*A= Authorization
*C= Claim
Insurance
SSN or
Date
Amount
Date
Amount
#
Patient Name
Policy Holder
A/C
Company
Welfare No.
Requested
Requested
Received
Received
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

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Parent category: Miscellaneous
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