form

Member Name

Address

Home Phone

Coverage:

Claim is for:

If Dependent,

Name of and Relationship

Provider

Service Date

Charge

Brief description

of problem

A copy of the bill and/or Explanation of Benefits can be sent or faxed to:

Linden Education Association

PO Box 3085

Linden, NJ 07036

Fax: 908-486-2580

(2000 character limit)

Insurance Problem Report Form

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Use this form to report any medical or dental problems.