Fax Cover Sheet
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1Fax Cover Sheet
UHG Ovations
Number of Documents:
_____
(i.e. Apps and/or Corr.)
Number of Pages Faxed:
____
Agent ID#:
Agent First Name:
____________
(All Caps)
Agent Last Name:
____________
(All Caps)
Agent Email:
_________________________________
Agent Phone #:
____-_____-________
Agency Name:
________________________________
Member 1 Name:
____________ ______________ ____ __ __ __ __ __
Pages
First
Last
CMS #
Member 2 Name:
____________ ______________ ____ __ __ __ __ __
First
Last
Pages
CMS #
Member 3 Name:
____________ ______________ ____ __ __ __ __ __
First
Last
Pages
CMS #
Member 4 Name:
____________ ______________ ____ __ __ __ __ __
First
Last
Pages
CMS #
Member 5 Name:
____________ ______________ ____ __ __ __ __ __
Pages
First
Last
CMS #
FaxSep
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Parent category: Business