Block · one region of the page, as the scanner read it. It may hold a whole story, part of one, several, or an advertisement; stitching blocks into articles is the next step. Text is supplied OCR.
Page 5 · spans the page · from the scan, no model involved
II. Certification Please attach copy(ies) of cancelled check(s) or paid covered facility invoice(s). This information may help Trigon process your claim Cancelled checks and covered facility invoices are not required, however, to be eligible for this program. Trigon reserves the right to verify payment from covered facility records. • ' 1 ... • ... V ' 1. * 1 understand the following: This claim must be signed and postmarked by midnight, January 7, 1995, to be eligible for reimbursement by Trigon. Trigon will calculate my refund, if any, by applying the average percentage covered facility discount to the amount of coinsurance 1 previously paid, plus interest at the legal rate of interest, compounded annually. “Coinsurance” does not include any amounts 1 have paid toward my deductible or for non-covqed services (such as TV, rentals, guest trays, etc.). ' This program does not apply to services covered under Medicare Supplemental products or the Federal Employees Program (FEP). For purposes of this program, the term policyholder means the named insured, subscriber, employee or member under a Trigon contract. For purposes of this program, the term covered facility includes hospitals, skilled nursing facilities, home health agencies, psychiatric/substance or alcohol abuse centers and ambulatory surgery facilities or other facilities that have been designated by Trigon as a participant in one or more of its provider networks. I certify that the information on this form is correct and 1 have paid the covered facility(ies). I authorize Trigon to obtain Confirmation from the covered facility to which 1 paid the coinsurance. Signature Date
78.9%