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Out-of-Network Care Claim Form - UPMC Health Plan

Out-of-Network Care Claim Form - UPMC Health Plan

www.upmchealthplan.com

Out-of-Network Care Claim Form • Both sides of this form must be completed. Incomplete forms will delay payment. • Complete sections 1-5. Have the doctor who treated you complete the

  Health, Form, Network, Care, Plan, Claim, Upmc health plan, Upmc, Out of network care claim form

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