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Get Uhc Demographic Update Form

Be unable to process incomplete forms. Complete all information pertaining to your practice. Please reference the Table on page 3. UnitedHealthcare and its affiliates/alliances are listed by Fax Number/State. Please fax your completed form to the appropriate fax number. Section I Group demographics Practice/Organization Name Current Tax ID (TIN) National Provider Identifier Date issued / / Please refer to Section III (page 2) of this fax form for taxonomy code definitions *Please list you.

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