Fax Cover Sheet Google Doc 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.

QuestionAnswer
Form NameGoogle Docs Fax Cover Sheet
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfax cover sheet google doc, google doc fax cover sheet, fax cover letter template google docs, fax cover sheet google docs

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

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