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BLUE CROSS
APPLICATION 65 EXTENDED Husband and wife must file separate applications BLUE SHIELD PLEASE PRINT PLEASE PRINT I wish to enroll as a Subscriber for the prepaid health care services offered by Virginia Hospital Service Association and Virginia Medical Service Association under the 65 Extended Contract. My Social Security Number_
Birth Month-Year_ □ Male □ Female Name: □ Miss □ Mrs. □ Mr. --------- (first name) (middle initial) (last name) Address: _ -*---ZIP Code . _ 0
Please bill me for this coverage every □ 2, Q 6, or Q 12 months Are you now a Blue Cross member?
□ YES | □ NO Blue Cross Plan of__ under Contract Number .. (city or state) 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 □ I have other health care care coverage except that coverage to supplement the provided by the Federal Federal Medicare program with: Medicare program. C. (nama of insurance company)
I certify that the information on this application is accurate to the best of my knowledge.
Applicant's V Form E-ioo-s Date--Signature ___ (46)
BLUE CROSS-BLUE SHIELD, *** prineeaa Anns Street, FrcAeridtsbnrg, Vs. 22441
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