Health Insurance Claim Form - The Empire Plan - United Healthcare Page 2

INSURANCE FRAUDS PREVENTION ACT

The following statement is printed pursuant to Regulation 95 of the New York State Insurance Department:

“Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact

material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to

exceed five thousand dollars and the stated value of the claim for each such violation.”

PLEASE MAIL CLAIMS TO: UnitedHealthcare

P.O. Box 1600

Kingston, New York 12402-1600

1-877-7NYSHIP (1-877-769-7447)

OR FAX TO (845) 336-7716

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Parent category: Medical