Page 20 - Private Information Guide
P. 20
HEALTH INSURANCE
Insurer Plan ID Group # Medicare #
Medigap/Supplemental
Plan Name
Issuer Group # ID #
Prescription Coverage
Prescription Coverage Issuer Group # ID #
(Medicare D)
Blood Type n n O n n B n n Positive
n n A n n AB n n Negative
VA Medical n n Yes Group # ID #
n n No
Additional Notes:
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