Mail SAMBA Claims To CIGNA P. O. Box 188007 Chattanooga TN 37422 301 984-1440 800 638-6589 HEALTH INSURANCE CLAIM FORM Instructions are shown on reverse side. MEDICAID Medicare CHAMPUS CHAMPVA Medicaid Sponsor s SSN VA File 2. PATIENT S NAME Last Name First Name Middle Initial GROUP HEALTH PLAN X FECA BLK LUNG OTHER SSN or ID SSN ID 3. PATIENT S BIRTH DATE MM DD YY 4. INSURED S NAME Last Name First Name Middle Initial F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Spouse Child 8....
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