ate: 02/05/2015 Please remit payment of $0.00 payable to: MITCHELL A Kt I NE, MD PC EFTA00282964 1500 HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UN FORM CLAIM COMMITTEE INUCC) OV12 UNITEDHEALTHCARE P 0 BOX 740800 ATLANTA GA 30374 RICA PiCA1 1 1 MEDICARE MEDICAID TRICARE OiNOINA GROUP