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The clipping this text was read from
The clipping this text was read from

APPLICATION BLUE CROSS 65 EXTENDED Husband and wife must file separate applications BLUE SHIELl PLEASE PRINT PLEASE PRIN1 ! w'sh to enroll as a Subscriber for the prepaid health care services offered by Virginia Hospital Serv ice Association and Virginia Medical Service Association under the 65 Extended Contract. My Social Security Number ____

Birth Month-Year_ □ Male [~] Female Name: □ Miss [J Mrs. □ Mr. - (first name) (middle initial) (last name) Address: ZIP Code

Please bill me foi this coverage every □ 2, □ 6, or □ 12 months Are you now a Blue Cross member? □ YES □ NO A Blue Cross w Plan of_ (city or state) under Contract Number _ If Blue Cross group coverage, .. _ .. give group's name and address: __ Do you have □ Spouse under 65 [~| Unmarried dependent children under 19 CHECK ONE □ I do not have other health care coverage except that provided by the Federal Medicare program. □ I have other health care coverage to supplement the Federal Medicare program with: (name of insurance company) I certify that the information on this applical on is accurate to the best of my knowledge. Applicant's Form E-ioo-s Date _ - _ Signature___ (45)

LUE CROSS-BLUE SHIELD, *•* Princess Anna Street, Fredericksbarg, Va. 224*1

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