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United HealthCare Ins. Co.


Student Resources Patient: ANDRES CEDENO
PO BOX 809025
DALLAS TX 75380-9025 Policy#: 16-0330-02
(800) 767-0700 Claim #: 16219781-01-02

Date: 01/12/2017

299 Diamond Village Apt# 10
Gainesville FL 32603


We are pleased that you are participating in an insurance plan provided by

UnitedHealthcare StudentResources.

Your UnitedHealthcare StudentResources Policy has either a Coordination of

Benefits or an Excess Coverage provision regarding other insurance. For
additional details on the provision, please review the plan brochure which
was provided to you when you purchased this coverage or online at www.uhcsr.
com. Before processing your claim(s) we need to obtain some additional
information regarding possible other insurance.

NOTE: If your policy has an Excess Coverage provision and you have other
medical insurance please mail all bills to that insurance company
immediately. When you receive the Explanation of Benefits (EOB) form(s) and/
or their claim denial letter(s) please forward us a copy of those documents.

You can provide the requested information using any of the following methods:

Login to
Email to
Fax to (469) 229-5625
Call Customer Service at the number on your ID card or (800) 767-0700
between the hours of 7:00 AM and 7:00 PM, Central Standard Time,
Monday through Friday
Mail to the address listed above

Please note, FAX or MAIL are the only secure methods of returning Protected
Health Information to UnitedHealthcare StudentResources. You may also email
your information; however, transmission via email is not a secured method. If
you elect to return information to UnitedHealthcare StudentResources via
email, you have voluntarily made the decision to utilize an unsecured

If you have other insurance coverage, please provide the following for each
member of your family covered under your student Insurance Policy:

Name of other insurance carrier: _________________________________

Policy Number: __________________________________

Group Number: __________________________________

Other Insurance Telephone #: _____________________________________

Policyholder's Name:
Policyholder's Address: __________________________________________

Policyholder's Date of Birth: ____________________________________

Effective Date: _____________ Termination Date: _________________

If dependent, what is your relationship to policyholder (circle one)?

Spouse/Domestic Partner, Child or Other: ___________________ (please

Date: ______________ Signature: ________________________________________

If you do not have any other coverage for yourself or any member of your
family under another insurance policy, please sign the following statement
and return this letter to us.

"I hereby certify that neither I, nor my spouse, nor any other
family members have any other type of medical insurance."

Date: ______________ Signature: __________________________________

IMPORTANT: We are dedicated to processing all claims as quickly as possible;

however, we need additional information in order to continue.
Unfortunately, if we do not receive this information in a timely manner, we
may have to deny all current and subsequent claims as being incomplete.

We appreciate your assistance in helping us process your claim as quickly as



Claims Department
LETTER DCN: 170129300764
SRID: 5059928