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UT SELECT Downloadable Forms
Click on the name to view forms in PDF format.
Medical Claim Form
(66 kb)
Transitional Benefits
(161 kb)
Provider Nomination Form
(85 kb)
UT SELECT Coordination of Benefits Questionnaire
(127 kb)
International Claim Form
(37 kb)
HIPAA Authorization Form to Disclose PHI
(21 kb)
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a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association.
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Health Care Service Corporation
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