Get the free When completed please mail this form and attachments to P

When completed, please mail this form and attachments to: P O Box 30555, Salt Lake City, UT 841300555 HEALTH CLAIM TRANSMITTAL CenturyLink Group Number: 229050 A. SUBSCRIBER/EMPLOYEE INFORMATION Subscriber#

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1. Write or type your full name in the designated field. This is important for identification purposes.
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3. Provide a valid email address. This is essential for electronic communication and updates related to your submission.
4. If applicable, include a phone number where you can be reached. It can be useful if there are any questions or clarifications required.
5. Indicate the date on which you completed the document. This is the date when you are submitting it for further processing or review.
6. Check for any additional instructions or requirements stated on the form. Make sure to follow them accordingly to avoid any complications.

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