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Get and Sign Unitedhealthcare Claim Reconsideration Form 2012-2022
Physician Hospital Other health care professional (Lab, Durable Medical Equipment (DME), etc)
(check one):
Medicare Medicaid MIChild
No new claims should be submitted with this form. Please submit a separate form for each claim.
Member information:
Member ID
Date of Service
Billed Amount
First
MI
Member Name
Last
Physician/health care professional information:
TIN
PIN
Phone Number
Physician Name
Last
Billing Address
First
State
Group Name
Contact Person
Zip
Amount...
Show details
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