Fax Cover Sheet - Upmc Health Plan, Form W-9 - Request For Taxpayer Identification Number And Certification - Department Of Treasury

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FAX COVER SHEET
To:
Network Management
Fax number:
412-454-5664
From:
_______________________
Fax number:
_______________________
Telephone number:
_______________________
Date:
_______________________
Subject:
Provider Change Form – Tax ID Form
Number of pages:
_______________________
(including this one)
Comments:
This facsimile contains privileged and confidential information intended only for the use of the named recipient. If
you are not the intended recipient of this facsimile or the employee or agent responsible for delivering to the
intended recipient, you are hereby notified that any dissemination or copying of this facsimile is strictly prohibited. If
you have received this facsimile in error, please notify the sender immediately and destroy this facsimile.
If this transmission contains patient information, this information has been disclosed to you from records whose
confidentiality is protected by state and federal law. Federal regulations (42 CFR Part 2) prohibits you from making
any further disclosure of this information without the specific written authorization of the person to whom it pertains
or as otherwise permitted by such regulations.

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