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Ating Provider Please fill out this form completely and attach any supporting documentation to: Fax #: (844)488-7050 You may also mail this form and any supporting documentation to: Molina Healthcare of Puerto Rico, Inc. Attention: Provider Claims Disputes/Adjustments PO Box 365068 San Juan, PR 00936-5068 PROVIDERS NOTE: Please send Corrected Claims as normal claim submissions via electronic or paper. Section 1: General Information Claim Number Member Id # (One claim per form) Member Name Date.

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