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Coordination of Benefits

Coordination of Benefits Questionairre

Instructions

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Are you or others in your family covered by other health plans, including Medicare or Medicaid, in addition to your WellSpan Population Health Services health plan?

***TO ENROLL YOUR DEPENDENT(S), PLEASE CONTACT YOUR HUMAN RESOURCES TEAM. COMPLETION OF THIS FORM DOES NOT ENROLL YOUR DEPENDENT(S) ON YOUR PLAN. *** Thank you.