Blue Blue 90100 012833FLBC Rx BINPCN Group Number ......your charge and our allowance. When...
4
XSLGBS11 08346 00001 8 EXPD S 90100001 01 WHITEWATER RAFTING 4800 DEERWOOD CAMPUS PKWY JACKSONVILLE FL 32256 APFIAPHLBICPHKAMGPANHOGOCK ADOLBAPKDCAPNLHOLJAKEDFCIK ACLMHCEELIAFCMCEHIILGKDLDK ABEHJPFAMLPLNIBDOMOMJNFMHK AMMANIJJCFCIMIJBPGBJIOLLFK AJLEBMKNIIDJKBDMOKGEAALFNK DDLDLLLLLDLLDLDDDDDDDLDLDL Select Select 012833 FLBC 90100 012833 FLBC 90100 WHITEWATER RAFTING WHITEWATER RAFTING A Local Network Plan A Local Network Plan Blue Blue Member Number BC BS Rx BIN PCN Group Number Member Number BC BS Rx BIN PCN Group Number XJK901000011 XJK901000011 090 590 090 590 ___________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________ ___________________________________________ ___________________________________________________ ___________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________ ___________________________________________ ___________________________________________________
Transcript of Blue Blue 90100 012833FLBC Rx BINPCN Group Number ......your charge and our allowance. When...
XSLGBS11 08346 00001 8
EXPD S
90100001 01
WHITEWATER RAFTING
4800 DEERWOOD CAMPUS PKWY
JACKSONVILLE FL 32256
APFIAPHLBICPHKAMGPANHOGOCK ADOLBAPKDCAPNLHOLJAKEDFCIK ACLMHCEELIAFCMCEHIILGKDLDK ABEHJPFAMLPLNIBDOMOMJNFMHK AMMANIJJCFCIMIJBPGBJIOLLFK AJLEBMKNIIDJKBDMOKGEAALFNK DDLDLLLLLDLLDLDDDDDDDLDLDL
Select
Select
012833
FLB
C
90100
012833
FLB
C
90100
WH
ITE
WA
TE
R R
AFT
ING
WH
ITE
WA
TE
R R
AFT
ING
A L
ocal N
etw
ork
Pla
n
A L
ocal N
etw
ork
Pla
n
Blu
e
Blu
e
Me
mbe
r N
um
ber
BC
BS
Rx B
IN
PC
N
Gro
up
Num
ber
Me
mbe
r N
um
ber
BC
BS
Rx B
IN
PC
N
Gro
up
Num
ber
XJK901000011
XJK901000011
090
590
090
590
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
No
tic
e t
o P
artic
ipatin
g P
ro
vid
er: C
olle
ct
for
coin
sura
nce,
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arm
acie
s: F
or
cla
ims s
ubm
issio
n a
nd
oth
er
help
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info
rmation
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it w
ww.bcbsfl.com.
No
tic
e t
o P
artic
ipatin
g P
ro
vid
er: C
olle
ct
for
coin
sura
nce,
Ph
arm
acie
s: F
or
cla
ims s
ubm
issio
n a
nd
oth
er
help
ful
info
rmation
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it w
ww.bcbsfl.com.
call t
he n
um
ber
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r vis
it www.bcbs.com.
Ou
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f-S
ta
te P
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vid
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it a
ll c
laim
s t
o t
he B
lue
call t
he n
um
ber
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r vis
it www.bcbs.com.
Ou
t-o
f-S
ta
te P
ro
vid
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ubm
it a
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laim
s t
o t
he B
lue
APFIAPHLBICPHKAMGPANHOGOCK ADOLBAPKDCAPNLHOLJAKEDFCIK ACLMHCEELIAFCMCEHIILGKDLDK ABEHJPFAMLPLNIBDOMOMJNFMHK AMMANIJJCFCIMIJBPGBJIOLLFK AJLEBMKNIIDJKBDMOKGEAALFNK DDLDLLLLLDLLDLDDDDDDDLDLDL
1-8
00-3
52-2
583
1-8
00-8
10-2
583
1-8
00-3
52-2
583
1-8
00-8
10-2
583
Custo
mer
Serv
ice:
ww
w.b
cbsfl.c
om
/MyB
lueS
erv
ice
Outs
ide o
f Flo
rida:
Custo
mer
Serv
ice:
ww
w.b
cbsfl.c
om
/MyB
lueS
erv
ice
Outs
ide o
f Flo
rida:
001001009
10000110108346000001
Flo
rid
a P
ro
vid
ers S
en
d C
laim
s t
o:
Flo
rid
a P
ro
vid
ers S
en
d C
laim
s t
o:
P.O
. B
OX
1798 J
AC
KS
ON
VIL
LE
, FL 3
2231
P.O
. B
OX
1798 J
AC
KS
ON
VIL
LE
, FL 3
2231
copay,
ded
uctib
le, an
d a
ny n
on-c
ove
red s
erv
ices o
nly
.
Patien
t is
no
t re
sp
on
sib
le f
or
the
diffe
rence b
etw
een
your
charg
e a
nd
ou
r allow
ance.
When s
ubm
ittin
g c
laim
s a
nd/o
r in
qu
irie
s, alw
ays in
clu
de
the n
am
e a
nd
co
mp
lete
me
mbe
r nu
mbe
r, in
clu
din
g t
he
alp
ha p
refix,
as s
ho
wn
on
the f
ron
t of
the
card
.
EP
O B
ene
fits
are
lim
ite
d t
o e
merg
ency s
erv
ice
s a
nd
care
wh
en p
rovid
ed
by a
non
-Exclu
siv
e P
rovid
er.
copay,
ded
uctib
le, an
d a
ny n
on-c
ove
red s
erv
ices o
nly
.
Patien
t is
no
t re
sp
on
sib
le f
or
the
diffe
rence b
etw
een
your
charg
e a
nd
ou
r allow
ance.
When s
ubm
ittin
g c
laim
s a
nd/o
r in
qu
irie
s, alw
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clu
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the n
am
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nd
co
mp
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me
mbe
r nu
mbe
r, in
clu
din
g t
he
alp
ha p
refix,
as s
ho
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on
the f
ron
t of
the
card
.
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O B
ene
fits
are
lim
ite
d t
o e
merg
ency s
erv
ice
s a
nd
care
wh
en p
rovid
ed
by a
non
-Exclu
siv
e P
rovid
er.
Blu
e C
ross a
nd B
lue S
hie
ld o
f Flo
rida is an
Indepen
dent
Lic
ensee o
f th
e B
lue C
ross a
nd B
lue
Shie
ld A
ssocia
tion.
Possessio
n o
f th
is c
ard
does n
ot
guara
nte
e e
ligib
ility
for
benefits
.
To
locate
a p
art
icip
ating p
rovid
er
outs
ide o
f Flo
rida,
Cro
ss a
nd B
lue S
hie
ld p
lan s
erv
ing y
our
are
a.
Blu
e C
ross a
nd B
lue S
hie
ld o
f Flo
rida is an
Indepen
dent
Lic
ensee o
f th
e B
lue C
ross a
nd B
lue
Shie
ld A
ssocia
tion.
Possessio
n o
f th
is c
ard
does n
ot
guara
nte
e e
ligib
ility
for
benefits
.
To
locate
a p
art
icip
ating p
rovid
er
outs
ide o
f Flo
rida,
Cro
ss a
nd B
lue S
hie
ld p
lan s
erv
ing y
our
are
a.
XSLGBS11 08346 00002 8
EXPD S
90100001 09
HORSERIDIN CAMP
8928 FREEDOM COMMERCE PKWY
JACKSONVILLE FL 32246
APFIAPHLBICNHKAMGPANHOGOCK ADOLBAPKDCAPNLHOLJAKFGFAIK ACLMHCEAPIAFCICFHMPENCBLDK ABEHJPFAMLPLMNGLGNODIBDMHK AMMANIJJDEDOAACBFPLHOMMJBK ALLEBOPEDOPLAPMEAAJMIBPHPK DLDDLLLLLLLLDLDDDLLDDLDLDL
Select
Select
A L
imit
ed
Ben
efi
t P
lan
012833
FLB
C
90100
A L
imit
ed
Ben
efi
t P
lan
012833
FLB
C
90100
HO
RS
ER
IDIN
CA
MP
HO
RS
ER
IDIN
CA
MP
A L
ocal N
etw
ork
Pla
n
A L
ocal N
etw
ork
Pla
n
Blu
e
Blu
e
Me
mbe
r N
um
ber
BC
BS
Rx B
IN
PC
N
Gro
up
Num
ber
Me
mbe
r N
um
ber
BC
BS
Rx B
IN
PC
N
Gro
up
Num
ber
XJK901000019
XJK901000019
090
590
090
590
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
____
____
______
______
__
_____________________________
___
___
____
___
___
___
___
___
____
___
___
___
___
__
___
___
____
___
___
___
___
___
____
___
___
___
___
__
____
____
______
______
__
_____________________________
No
tic
e t
o P
artic
ipatin
g P
ro
vid
er: C
olle
ct
for
coin
sura
nce,
Ph
arm
acie
s: F
or
cla
ims s
ubm
issio
n a
nd
oth
er
help
ful
info
rmation
, vis
it w
ww.bcbsfl.com.
No
tic
e t
o P
artic
ipatin
g P
ro
vid
er: C
olle
ct
for
coin
sura
nce,
Ph
arm
acie
s: F
or
cla
ims s
ubm
issio
n a
nd
oth
er
help
ful
info
rmation
, vis
it w
ww.bcbsfl.com.
call t
he n
um
ber
above o
r vis
it www.bcbs.com.
Ou
t-o
f-S
ta
te P
ro
vid
er: S
ubm
it a
ll c
laim
s t
o t
he B
lue
call t
he n
um
ber
above o
r vis
it www.bcbs.com.
Ou
t-o
f-S
ta
te P
ro
vid
er: S
ubm
it a
ll c
laim
s t
o t
he B
lue
APFIAPHLBICNHKAMGPANHOGOCK ADOLBAPKDCAPNLHOLJAKFGFAIK ACLMHCEAPIAFCICFHMPENCBLDK ABEHJPFAMLPLMNGLGNODIBDMHK AMMANIJJDEDOAACBFPLHOMMJBK ALLEBOPEDOPLAPMEAAJMIBPHPK DLDDLLLLLLLLDLDDDLLDDLDLDL
1-8
00-3
52-2
583
1-8
00-8
10-2
583
1-8
00-3
52-2
583
1-8
00-8
10-2
583
Custo
mer
Serv
ice:
ww
w.b
cbsfl.c
om
/MyB
lueS
erv
ice
Outs
ide o
f Flo
rida:
Custo
mer
Serv
ice:
ww
w.b
cbsfl.c
om
/MyB
lueS
erv
ice
Outs
ide o
f Flo
rida:
001001009
10000190108346000002
Flo
rid
a P
ro
vid
ers S
en
d C
laim
s t
o:
Flo
rid
a P
ro
vid
ers S
en
d C
laim
s t
o:
P.O
. B
OX
1798 J
AC
KS
ON
VIL
LE
, FL 3
2231
P.O
. B
OX
1798 J
AC
KS
ON
VIL
LE
, FL 3
2231
copay,
ded
uctib
le, an
d a
ny n
on-c
ove
red s
erv
ices o
nly
.
Patien
t is
no
t re
sp
on
sib
le f
or
the
diffe
rence b
etw
een
your
charg
e a
nd
ou
r allow
ance.
When s
ubm
ittin
g c
laim
s a
nd/o
r in
qu
irie
s, alw
ays in
clu
de
the n
am
e a
nd
co
mp
lete
me
mbe
r nu
mbe
r, in
clu
din
g t
he
alp
ha p
refix,
as s
ho
wn
on
the f
ron
t of
the
card
.
EP
O B
ene
fits
are
lim
ite
d t
o e
merg
ency s
erv
ice
s a
nd
care
wh
en p
rovid
ed
by a
non
-Exclu
siv
e P
rovid
er.
copay,
ded
uctib
le, an
d a
ny n
on-c
ove
red s
erv
ices o
nly
.
Patien
t is
no
t re
sp
on
sib
le f
or
the
diffe
rence b
etw
een
your
charg
e a
nd
ou
r allow
ance.
When s
ubm
ittin
g c
laim
s a
nd/o
r in
qu
irie
s, alw
ays in
clu
de
the n
am
e a
nd
co
mp
lete
me
mbe
r nu
mbe
r, in
clu
din
g t
he
alp
ha p
refix,
as s
ho
wn
on
the f
ron
t of
the
card
.
EP
O B
ene
fits
are
lim
ite
d t
o e
merg
ency s
erv
ice
s a
nd
care
wh
en p
rovid
ed
by a
non
-Exclu
siv
e P
rovid
er.
Blu
e C
ross a
nd B
lue S
hie
ld o
f Flo
rida is an
Indepen
dent
Lic
ensee o
f th
e B
lue C
ross a
nd B
lue
Shie
ld A
ssocia
tion.
Possessio
n o
f th
is c
ard
does n
ot
guara
nte
e e
ligib
ility
for
benefits
.
To
locate
a p
art
icip
ating p
rovid
er
outs
ide o
f Flo
rida,
Cro
ss a
nd B
lue S
hie
ld p
lan s
erv
ing y
our
are
a.
Blu
e C
ross a
nd B
lue S
hie
ld o
f Flo
rida is an
Indepen
dent
Lic
ensee o
f th
e B
lue C
ross a
nd B
lue
Shie
ld A
ssocia
tion.
Possessio
n o
f th
is c
ard
does n
ot
guara
nte
e e
ligib
ility
for
benefits
.
To
locate
a p
art
icip
ating p
rovid
er
outs
ide o
f Flo
rida,
Cro
ss a
nd B
lue S
hie
ld p
lan s
erv
ing y
our
are
a.
