Get the free UHC Out-of-Network Claim Form - employeebenefits ri
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HEALTH CLAIM TRANSMITTAL
P.O. BOX 740800
ATLANTA, GA 30374-0800
A. MEMBER/EMPLOYEE INFORMATION
Member # (SSN):
—
Phone #:
—
(
Last
Name:
Home
Address:
City:
First
Name:
Spouse
Last Name:
First
Name:
MI:
First
Name:
)
MI:
MI:
State:
Date
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