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Get Ufcw Predetermination Form

UBSCRIBER INFORMATION (For Insurance Company Named in #3) 2. Predetermination / Preauthorization Number 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION Policyholder Name Address 1 Address 2 City 3. Company/Plan Name, Address, City, State, Zip Code EBS-RMSCO PO Box 780 Liverpool ST NY M 13088-0780 OTHER COVERAGE 16. Plan/Group Number 4. Other Dental or Medical Coverage? ZIP 15. P.

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