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RetiRee Medical SavingS account Premium expense ...

For Information or Answers to YourQuestions: (866) 278-0771 Fax or Mail Completed form To: UnitedHealthcare Service Center Box 740378 Atlanta, GA 30374 Fax: (248) 733-6144 RetiRee Medical SavingS account Premium expense reimbursement Request FormTo ensure the timely reimbursement of your eligible premiums, follow these steps to complete and submit this form : STEP 1: Get your RetiRee ID number. This is your Prudential Active Employee ID number. If you don t know it, call thePrudential Benefits Center at 1-800-PRU-EASY (1-800-778-3279) and follow the prompts for Health and Welfare Service Representatives are available to assist you from 8 to 6 , Eastern time, Monday to Fridayexcept holidays. For the hearing-impaired, please contact your local relay service. Keep a record of this number withyour other important personal information for future use. Claims cannot be processed without this 2: Gather your Premium receipts and evidence of payment for each eligible expense .

Fax or Mail Completed Form To: UnitedHealthcare Service Center P.O. Box 740378 Atlanta, GA 30374 Fax: (248) 733-6144 RetiRee Medical SavingS account Premium expense Reimbursement Request Form To ensure the timely reimbursement of your eligible premiums, follow these steps to complete and submit this form: STEP 1: Get your Retiree ID number ...

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