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Return this form to: Accounts Receivable Dept. Mailing Address: Advance Freedom Coventry Health Care, Inc. Attn: A/R ACH Dept. 2222 Ewing Rd Moon Township, PA 15108 Toll Free Fax Number: 1 (866) 415-2232

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1. Carefully read and understand the instructions provided with the form.
2. Begin by entering the required personal information, such as your name, address, and contact details, in the designated fields.
3. Follow the instructions to provide any additional information that may be required, such as your social security number or tax identification number.
4. Take special care in filling out any financial or tax-related sections, ensuring accurate and complete information.
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6. If any sections of the form are not applicable to you, mark them as "N/A" or "Not Applicable" to avoid any confusion.
7. Make sure to sign and date the form where required. In some cases, you may need to provide additional signatures from witnesses or authorized individuals.
8. Review the completed form one final time to ensure all information is accurate and legible.
9. Once you are confident that the form is filled out correctly, follow the instructions provided on where to send the form.
10. Keep a copy of the completed form for your records.

Who Needs to Return This Form To:

1. The form should be returned to the appropriate agency or organization that requested it. This can vary depending on the purpose of the form and the instructions provided.
2. In some cases, the form may need to be submitted to a government entity, such as a tax office or a regulatory body.
3. Other times, the form may need to be returned to a specific department or individual within an organization, such as a human resources department or a customer service representative.
4. It is important to carefully read the instructions accompanying the form to determine the correct recipient.
5. If you are uncertain about where to return the form, you can reach out to the issuing agency or organization for clarification.

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What is return this form to?

Return this form to the specified address or department.

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