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Ufcwtrust. com Statement of Claim for Chiropractic/Acupuncture Benefits THIS FORM IS REQUIRED TO PROCESS YOUR CLAIM FOR CHIROPRACTIC/ACUPUNCTURE SERVICES Form to be used only for UEBT HMO Participants under 2005 and 2007 ratified Collective Bargaining Agreements MEMBER INFORMATION To be completed by Member Member Name Please Print Member SS Last Name First Name Middle Initial Street address P. MAIL CLAIM TO 2200 PROFESSIONAL DRIVE SUITE 200 ROSEVILLE CA 95661 Telephone 800 552-2400 Facsimile...
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