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Get UnitedHealthCare OVEX10MP3170778

I authorize OptumHealth Financial Services (OHFS), an affiliate of UnitedHealthcare, to deposit my reimbursements into the bank account(s) shown below. I authorize credit entries and, if necessary, debit entries and any adjustments for credit entries made in error. Employer Name Employee/Retiree Name Social Security Number ....................–....................–.................... This request is: New A change Name of Bank A cancellation Bank Phone Number (.................).

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