BALANCE BILLING COMPLAINT

UNION PACIFIC HEALTH SYSTEMS
P.O. BOX 4136
SALT LAKE CITY, UTAH 84110 - 4136

PLEASE SEND THIS COMPLETED FORM TO UNION PACIFIC HEALTH SYSTEMS. OUR
REPRESENTATIVE WILL CONTACT THE PROVIDER.

PLAN:______________________________________________________________________

WHFA GROUP #:___________________________DATE:_____________________________

PROVIDER:__________________________________________________________________

ADDRESS:__________________________________________________________________

____________________________________________________________________________

PATIENT NAME:______________________________________________________________

MEMBER NAME:______________________________________________________________

MEMBER HI #:________________________________________________________________

DATE(S) OF SERVICE:_________________________________________________________

AMOUNT BEING BALANCE-BILLED:_____________________________________________

DEAR PROVIDER:

UPHS HAS RECEIVED A COMPLAINT THAT YOU HAVE BALANCE-BILLED THE ABOVE
NAMED PATIENT.

ACCORDING TO OUR AGREEMENT, YOU HAVE CONSENTED TO ACCEPT THE
CONTRACTED FEE AS PAYMENT IN FULL FOR WYOMING HEALTH FUND ALLIANCE
MEMBERS. PAYMENT FOR THIS SERVICE HAS BEEN MADE ACCORDING TO OUR
AGREEMENT AMOUNT. THE PATIENT HAS RECEIVED A BALANCE-BILL FROM YOU.
PLEASE CORRECT YOUR RECORDS AND ABIDE BY OUR CONTRACTED FEE IN THE
FUTURE.

IF YOU WISH TO DISCUSS THIS CLAIM, PLEASE CONTACT:

JUDY RAUSCHMEIER ( 801 ) 595-4364

DEBORAH FORBUSH ( 801 ) 595-4336