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Box 30760 Salt Lake City, UT 84130-0760 Fax #: (248) 733-6079 HEALTH CLAIM TRANSMITTAL A. SUBSCRIBER/EMPLOYEE INFORMATION Subscriber/Member #: Phone #: Last Name: Home Address: City: First Name: Spouse Last Name: MI: First Name: Date of Birth: MI: New Address: Yes No Zip Code: Spouse Date of Birth: MI: Date of Birth: State: B. PATIENT INFORMATION Last Name: Home Address: City: Sex: M F First Name: State: Relationship To subscriber: Full Time Student: Yes No Zip Code: School .

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