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. Day lYr MALE FEMALE SELF SPOUSE CHILD OTHER OCCUPATION EMPLOYER COVERED BYI MEDICARE? YES NO DATE IFYES, EFFECTIVE Mo. (HOSP) I ...
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