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Get Fill Upmc Form For Education

Name Relationship Please return this completed form by mail to P. O. Box 2965 Pittsburgh Pennsylvania 15230-2965 or by fax to 412-454-7829 In this document the term UPMC Health Plan refers to benefit plans offered by UPMC Health Network Inc. and UPMC Health Benefits Inc. as well as UPMC Health Plan Inc. If you have any questions about this Personal Representative Designation Form please call the Member Services Department at the telephone number.

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