State of Connecticut Emergency Room Copayment ...
The patient identified above had a Medical Emergency that placed his or her health in serious jeopardy or ... (Print Name of School) By signing this form, I hereby certify that the information provided is true and complete to the best of my knowledge. ... Return form to Anthem/State of CT, PO Box 554, North Haven, CT 06473 or fax to 855-394-3747 ................
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