UNION PACIFIC HEALTH SYSTEMS

WHFA AFFILIATE INFORMATION FORM

PLAN:______________________________________________________________________

WHFA GROUP # ________________________PAYER ID # ____________________________

EFFECTIVE DATE:______________________ NUMBER OF COVERED LIVES:___________

NAME & ADDRESS OF CONTACT:_______________________________________________

____________________________________________________________________________

TELEPHONE:(_____)____________________FAX:(_____)____________________________

FINANCIAL INFORMATION:

NAME & ADDRESS OF CONTACT FOR REPORTS & INVOICING:______________________

____________________________________________________________________________

____________________________________________________________________________

TELEPHONE:(_____)____________________FAX:(_____)____________________________

HEALTH PLAN ADMINISTRATION INFORMATION:

PLAN ADMINISTRATOR NAME & ADDRESS (TPA, SELF, ETC.):_______________________

____________________________________________________________________________

____________________________________________________________________________

CONTACT PERSON CLAIMS:___________________________________________________

TELEPHONE:(_____)____________________FAX:(_____)___________________________

CONTACT PERSON ADJUSTMENTS:____________________________________________

TELEPHONE:(_____)____________________FAX:(_____)___________________________

PLEASE FORWARD THIS COMPLETED FORM IMMEDIATELY TO UNION PACIFIC HEALTH
SYSTEMS, P.O. BOX 4136, SALT LAKE CITY, UTAH 84110 - 4136