PRODUCT AND BENEFIT SELECTION FORM (1-100) - UHC


Product and Benefit Selection Form (1-100) 1. Group Name. 2. Medical Plan Code(s) Rx Plan Code(s) 3a. Dental Plan Code(s) 3b. Has this group been covered for major dental services for the previous 12 consecutive months?

  • File type: PDF
  • File size: n/a
  • File name: product-selection-form-se-region.pdf
  • Source: broker.uhc.com


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