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hc.com Care24: Mental Health: For Providers: www.undedhealthcareonlIne. Medical Claims: P.O. BOX 7408@ ATLANTA GA3037 Portal 18121109 clams, or Fonda cemeccocce YAW liMuiriPter Pharmacy Claims:PO BOX 14711, LEXINGTON KY 40512 Foe Pharmacists 800122-155T EFTA00311071 Li/ Zell ME PSC gain C
e. O \led:eaid Obtaining a referral authorization from your primary care physician as needed. No payment is due at the time of service. File the Medicaid claim. O Worker's Compensation If you supply our staff with a valid case number Call your carrier ahead of time to verify the accident date, clai
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Y PHYSICIAN (46) PHYSICIAN PHONE (48) Does your child currently have health insurance? MI YES 0 NO If YES, indicate: (47) HOSPITAL PREFERENCE 0 Medicaid 0 Private 0 Healthy Kids/kQd Care 0 Interested In receiving information ASWALOA491.4:04iiit lit filierAlaffiblikr0S-1-101)1; . .. (49) NAME CF
TER FOR ONE CODE ONLY. A 1-avo oortniuusy Toed n Fonda for the past year or longer. D 9 have puichmed
um fluoride program (Permission is valid (hmugh grade 6) YES (27) Does your child currently have health insurance? 0 YES 0 NO If YES, indicate: 0 Medicaid 0 Healthy Kids/Kid Care 0 Private (29) NOME LANGUAGE SURVEY (Chock so that Appy) 0 A language other than English Is used in the home. 0 The stude
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