1. BLUE CROSS BLUE SHIELD
PO BOX 1121
MEDICAL PA 12357-1121
X ZJW334444
TIGER, KATLYN 01 03 1954 X TIGER, KATLYN
2 JUNGLE ROAD
NOWHERE NY
12346-1234 101 1112222
X 2 JUNGLE ROAD
NOWHERE NY
12346-1234 101 1112222
X
X
X
X
X
W310
01 03 1954 X
JOHN LION CPA
BLUE CROSS BLUE SHIELD
X
SIGNATURE ON FILE MM DD YY SIGNATURE ON FILE
02 28 YYYY
02 28 YYYY 03 01 YYYY
X
485
02 28 YY 22 99220 1 175 00 1
03 01 YY 22 99217 1 65 00 1
111234632 X 1-4 X 240 00 000 240 00
ARNOLD J YOUNGLOVE MD
MM DD YY
GOODMEDICINE HOSPITAL
1 PROVIDER STREET
ANYWHERE NY 12345
1123456789
101 2027754
ARNOLD J YOUNGLOVE MD
21 PROVIDER STREET
INJURY NY 12347
0123456789