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Get Return Funds Form - Tufts Health Plan

Umber: Contact address: Check off all that apply: I am returning a check to Tufts Health Plan Please indicate the Statement of Account (SOA) number and the claim number below: SOA number Claim number I am writing a check to Tufts Health Plan Please indicate the Statement of Account (SOA) number and the claim number below: SOA number Claim number I have enclosed a copy of the SOA Please explain why you are returning funds to Tufts Health Plan in.

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