REPRICED CLAIM ADJUSTMENT REQUEST

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

PLEASE MAIL THIS COMPLETED FORM TO UNION PACIFIC HEALTH SYSTEMS.

PLEASE REMOVE THE FOLLOWING CLAIM FROM OUR WHFA GROUP FINANCIAL RECORD:

PLAN:_______________________________________________________________________

WHFA GROUP # __________________________DATE:_______________________________

PLAN ADMINISTRATOR:________________________________________________________

PERSON REQUESTING ADJUSTMENT:___________________________________________

TELEPHONE:(_____)______________________FAX:(_____)__________________________

ADDRESS:___________________________________________________________________

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MEMBER NAME:______________________________________________________________

MEMBER HI # ________________________________________________________________

PATIENT NAME:______________________________________________________________

ADMISSION OR SERVICE DATE(S):______________________________________________

HOSPITAL OR PROVIDER:_____________________________________________________

WE ARE UNABLE TO PAY AT THE REPRICED AMOUNT FOR THE FOLLOWING REASON(S):

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