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Get And Sign Unitedhealthcare Claim Reconsideration Form 2012-2021

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...

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