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Please mail label receipt s and this completed form to UnitedHealthcare ATTN Pharmacy Department 4 Gateway Center 4th floor Newark NJ 07102 M0011071107MO01 12/07. X Member s/Subscriber s Signature Date Special Instructions Prescription Label receipt must have the following information clearly legible or reimbursement could be delayed or denied. Physician receipt must have those items listed with an asterisk or reimbursement could be delayed or denied. Pharmacy Name Drug name strength and...
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