Google Docs Fax Cover Sheet – Fill Out and Use This PDF

Google Docs Fax Cover Sheet is a creative way to save time and effort. Instead of using the fax machine, send your documents directly from Google Docs to their recipient as a fax.

Working with this form has never been easier. Simply hit the orange button below and enjoy the advantages of using our PDF tool with lots of features in the toolbar.

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Google Docs Fax Cover Sheet PDF Details

If you need to send a fax, you can use the Google Docs Fax Cover Sheet Form to create a cover sheet for your fax. This form includes fields for your name, the recipient's name, the subject of the fax, and the body of the fax. You can also include a logo or other image in the cover sheet. The Google Docs Fax Cover Sheet Form is easy to use and helps you to create a professional-looking fax cover sheet.

If you would like know some specific details about the PDF you're going to use, here's the specifics you might like to read before completing the google docs fax cover sheet.

Question	Answer
Form Name	Google Docs Fax Cover Sheet
Form Length	2 pages
Fillable?	Yes
Fillable fields	46
Avg. time to fill out	9 min 46 sec
Other names	google fax cover sheet, fax template google docs, google docs fax cover sheet, 248 733 6000

12

Form Preview Example

PricewaterhouseCoopers

Group # 752713

Member Services: (888) 792-1545

For Medical Claims:	For Mental Health/Substance Use Claims:
PO Box 740809	PO Box 30760
Atlanta, GA 30374-0809	Salt Lake City, UT 84130-0760
Fax #: (248) 733-6000	Fax #: (248) 733-6079

HEALTH CLAIM TRANSMITTAL

A. SUBSCRIBER/EMPLOYEE INFORMATION

Subscriber/Member #:

Phone #:

Last

First

MI:

Date of Birth:

Name:

Name:

Home

New

Address:

Address: Yes No

City:

State:

Zip

Code:

Spouse

First

MI:

Spouse Date of Birth:

Last Name:

Name:

B. PATIENT INFORMATION

Last

First

MI:

Date of Birth:

Name:

Name:

Home

Address:

City:

State:

Zip

Code:

Sex:

Relationship

Full Time Student:

School

School Phone #:

M F

To subscriber:

Yes

No

Name:

C. ACCIDENT INFORMATION

Work

Auto

Date Accident

Accident?

Yes

No

Accident:

Yes

No

Occurred:

How did the

Accident Occur:

D. OTHER INSURANCE

Is the patient covered

by another plan?

Yes

No

If yes, please complete the following

Name of the person

Date of Birth:

carrying other insurance:

Member #:

Name of Other

Insurance Carrier:

Policy

Employer

Number:

Name:

ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY MISREPRESENTATION OR

ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE

UNDER LAW AND MAY BE SUBJECT TO CIVIL PENALTIES.

Member Signature:

Date:

E. ASSIGNMENT OF BENEFITS

Please sign below only if you want UnitedHealthcare to pay benefits directly to the provider of medical/mental health/ substance abuse services.

Signature:Date:

F. GUIDELINES FOR SUBMITTING CLAIMS TO UNITEDHEALTHCARE

•Clip, do not staple, all bills to the completed form and mail them to UnitedHealthcare at the address listed on your ID card at the address on top of this claim form.

•Submit all claims to UnitedHealthcare ina timely manner.

•Be sure to notify your employer of alladdress changes.

•Please include your Subscriber Number or Member Number on all documents.

Make sure that all bills include the following:

•Employee and Member information including address

•Patient and/or guardian name

•Diagnosis code from the provider

•Dates of Service – Each date of service should be specified

•Place of Service – Physician’s Office, Outpatient Facility, etc.

•CPT Codes

•Billed amount

•Provider tax id number

•Claim total

•Name of provider

•Address where services were rendered

•Billing Address

How to Edit Google Docs Fax Cover Sheet Online for Free

It is easy to obtain forms working with our PDF editor. Revising the docs fax sheet document is not difficult should you keep up with the following actions:

Step 1: You can press the orange "Get Form Now" button at the top of the following website page.

Step 2: You can see each of the actions that you may take on your document once you have accessed the docs fax sheet editing page.

To be able to obtain the document, enter the data the software will ask you to for each of the next areas:

part 1 to filling in google docs fax cover sheet template

The software will require you to submit the Yes, Policy, Number Name, of, Other, Insurance, Carrier, Employer Name, Member, Signature E, ASSIGNMENT, OF, BENEFITS Date, Signature, and Date area.

stage 2 to completing google docs fax cover sheet template

Step 3: Select "Done". Now you can transfer the PDF file.

Step 4: Ensure you avoid possible future difficulties by creating around two duplicates of your file.

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