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ENROLLMENT FORM FOR COVERAGE UNDER GROUP POLICY GA23111
*INSTRUCTIONS*
1. Please print all entries in ink. SOCIAL SECURITY NUMBER IS REQUIRED.
2. If the employee or any dependent is covered under
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myuhc is an online platform provided by UnitedHealthcare for managing healthcare benefits and services.
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Individuals enrolled in UnitedHealthcare plans may be required to file information on myuhc.
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