CLAIM REPRICING REQUEST

THIS FORM IS A COVER-SHEET TO FAX OR MAIL CLAIMS FOR REPRICING. MULTIPLE
CLAIMS MAY BE ATTACHED TO THIS FORM. PLEASE COMPLETE ALL INFORMATION.

MAIL CLAIMS TO:

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

OR FAX CLAIMS TO:

( 801 ) 595-2064 JUDY RAUSCHMEIER TELEPHONE: ( 801 ) 595-4364
UPHS CONTACT PERSON FOR CLAIMS INFORMATION

OR

( 801 ) 595-2036 DEBORAH FORBUSH TELEPHONE: ( 801 ) 595-4336
UPHS CONTACT PERSON FOR CLAIMS INFORMATION

SENDER INFORMATION:

PLAN:______________________________________________________________________

WHFA GROUP # _____________________________________________________________

PLAN ADMINISTRATOR (SELF, TPA, ETC.):_______________________________________

ADDRESS:__________________________________________________________________

CONTACT PERSON:__________________________________________________________

TELEPHONE: (_____)______________________FAX:(_____)_________________________

# OF CLAIMS ATTACHED___________________DATE SENT:________________________

NOTES:____________________________________________________________________

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