United Healthcare (Oxford) Eligibility Verification Form

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Risk Management MN012-N123
5901 Lincoln Drive
Edina, MN 55436-1611
October 8, 2010
«GroupName»
Attn: «GroupContact»
«GroupAddress»
«GroupAddress2»
«GroupCity», «GroupState» «GroupZip»
RE:
ELIGIBILITY VERIFICATION – YOUR RESPONSE IS REQUIRED
Group Name: «GroupName»
Group Number: «CustomerNumber»
Renewal Date: «CancelDate»
Dear «GroupContact»,
We appreciate your continued business with Oxford as a valued small business policyholder. Your health
insurance renewal rates and related information for the upcoming plan year will be mailed to you soon. In
preparation for your renewal, we are writing to you, today, to ask that you complete the attached
Employer Information Form and return it to us, along with supporting tax documentation, so we can
confirm that your group continues to meet the employee and group eligibility guidelines defined in your
policy.
Please note that if we do not receive the appropriate and complete documentation from you by
your renewal date, your group’s coverage will not be renewed. Your policy will be canceled as of
your renewal date.
You may receive additional policy renewal information prior to the renewal date shown above; however, if
eligibility requirements are not confirmed, the renewal information will become invalid and, as mentioned
above, your policy will be cancelled as of your renewal date.
Because Oxford is a UnitedHealthcare company, please send all required information, including the
Employer Information Form and supporting tax documents, to:
Mail:
UnitedHealthcare Risk Management MN012-N123
5901 Lincoln Drive
Edina, MN 55436-1611
Fax:
1-877-232-7902
E-mail:
Your assistance is vital, and we appreciate your cooperation. If you have questions about this request,
please see the attached instructions and Frequently Asked Questions sheet, send us an e-mail at
or call us at «1-xxx-xxx-xxxx». Please remember to include your full name,
group number, and telephone number with area code in any e-mail or voice-mail message.
All forms and tax documentation submitted are considered confidential and proprietary and will be used
only in the Risk Management Department for verification of eligibility requirements.
Sincerely,
Risk Management
: «BrokerName»
CC
Enclosures: Employer Information Form, Instructions/Frequently Asked Questions sheet, envelope
NY-10-748

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