Upmc for life flex spend card catalog

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use this card to help pay your out-of-pocket costs. Or -the-Counter lowance. You have an allowance you can use to help pay for health care products. See the UPMC . for Life. Flex Spend Card above for more details. Silvereakers ¯ FREE unlimited gym memberships. and one . FREE. personal training session each year at participating fitness ...At checkout simply swipe your UPMC for Life Flex Spend Card to pay for covered products. Where can I use my UPMC OTC card? If you want to shop for OTC products and healthy foods in-person, you can use your card at any of our participating retail stores, including Giant Eagle, Kroger, Rite Aid, Walgreens, and Walmart.UPMC for Life. 7,321 likes · 7 talking about this. UPMC for Life is a product of and operated by UPMC Health Plan, Inc., UPMC Health Network, Inc., anduse this card to help pay your out-of-pocket costs. Or -the-Counter lowance. You have an allowance you can use to help pay for health care products. See the UPMC . for Life. Flex Spend Card above for more details. Silvereakers ¯ FREE unlimited gym memberships. and one . FREE. personal training session each year at participating fitness ...Online Original Medicare, look in your current "Medicare & You" handbook that you received in the fall. You can view it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. Member IDCard. TTY users should call. 1-877-486-2048.New UPMC for Life Flex Spend Card! Your health care dollars, your choice. Many UPMC for Life plans get a UPMC for Life Flex Spend Card that gives you health care dollars to spend on over-the-counter (OTC) products, medical services like doctor’s office copays, and dental, vision, and hearing services. These dollars are in addition to any ...UPMC Health PlanMental health services *. Inpatient: $165 per day for days 1-5 and $0 per day for days 6 and beyond; Outpatient therapy: $35 per visit, $35 per telehealth visit. Inpatient: $300 per day for days 1-5 and $0 for days 6 and beyond; Outpatient therapy: $45 per in-person visit. Skilled nursing facility*.

UPMC Health PlanOther physicians/providers are available in the UPMC for Life network. This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical ...Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal.UPMC Health Plan. Attn: UPMC for Life. U.S. Steel Tower, 9th Floor. 600 Grant Street. Pittsburgh, PA 15219. This information is not a complete description of benefits. Call 1-844-575-8241 (TTY: 711) for more information. This information is available for free in other languages. Please call our customer service number at 1-800-606-8648 (TTY: 711).Check Your Card Balance. Quickly and easily check the balance on your card without logging into your account! Simply enter your card number and security code, which may be located on either the front or back of your card. Card number*. Security code*. CHECK BALANCE. Easily check your account balance without logging into your account.Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) are health benefit accounts that allow you to pay for out-of-pocket medical expenses with pre-tax dollars. FSAs are a benefit offered by your employer while HSAs are a benefit offered with high deductible insurance plans (HDHPs). ... You can use your FSA or HSA card both ...About the Provider Search Tool. Compare hospitals and the quality of care provided to patients. ABMS AOA. *Disclaimer: This online directory provides a list of UPMC Health Plan providers, and the information contained here is updated periodically. However, some plan providers may have been added or removed from the list (and/or contact ...See a snapshot of your health care spending, view your recent claims, access your member ID card, and review your plan details and documents. Care. Call your primary care provider or search for a new one, find a pharmacy, link to the UPMC AnywhereCare app to have a virtual visit, or talk to a nurse through the UPMC MyHealth 24/7 Nurse Line ...

That is couple text wealth could use here for a description of what it is we're saying on the secondly slide.Get the latest Medicare new & updates. UPMC for Life Health Plan | OTC | Over the Counter | Login Register | Enrollment Support and resources for: Need to contact or place a phone call to Call DrugSource: 1-877-418-8821 (TTY: 711) Contact Line for Current Members: Please first call the.Other physicians/providers are available in the UPMC for Life network. This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical ...UPMC for Life HMO Premier Rx Premium, Deductible, and Out-of-Pocket Limit Monthly plan premium $0 per month Annual deductible No deductible $4,900 for Medicare-covered services, including copays and coinsurance; Your out-of-pocket spending limit for the year. This is not a deductible and does not include costs for Part D prescription drugs.

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Hotel stays, weekend getaways and free gas are just a few of the things you can earn with credit card rewards. These programs reward you for every dollar you spend, often saving yo...Other physicians/providers are available in the UPMC for Life network. This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical ...Shop thousands of FSA (Flexible Spending Account) and HSA (Health Savings Account) eligible items at CVS Pharmacy online and in store today!UPMC for Life Flex Spend Card and Over-the-Counter (OTC) Mail-Order Catalog Your health care dollars, your choice! 202 3 5103 1234 5678 9010 GOOD THRU 12/23 J SMITH FLEX SPEND CARD ... REMEMBER TO KEEP THIS CATALOG. This catalog explains how your UPMC for Life Flex Spend Card works.From there, you can start ordering OTC products as part of your UPMC for Life Flex Spend Card or UPMC for Life Complete Care (HMO SNP) Shop Healthy Card benefit. Thank you for being a UPMC for Life member! Need Help? 1-800-688-2515 (TTY: 711) Monday - Friday, Hours 8:00 AM to 11:00 PM EST.That is couple text wealth could use here for a description of what it is we're saying on the secondly slide.

UPMC for Life Flex Spend Card and Over-the-Counter (OTC) Mail-Order Catalog Your health care dollars, your choice! 202 3 5103 1234 5678 9010 GOOD THRU 12/23 J SMITH FLEX SPEND CARD ... REMEMBER TO KEEP THIS CATALOG. This catalog explains how your UPMC for Life Flex Spend Card works.The HIA allows you to earn up to $75 for Self Only coverage and up to $150 for Self Plus One or Self and Family coverage. If you earn the rewards UPMC Health Plan's premium pass-through will fund your health savings account (HSA) or health reimbursement arrangement (HRA; applicable if you are not eligible for an HSA).Check Balance. Quickly and easily check the balance on your card without logging into your account! Simply enter your card number and security code, which may be located on either the front or back of your card. Card number*. Security code*. CHECK BALANCE.Use the 2024 UPMC for Life Complete Care Our Healthy Card katalogseite until learn more over the Shop Healthy Card and see the complete tabbed away mail-order products. Thee cans also shop for the UPMC for Spirit Complete Care plan in your area. This information is not one finished description of benefits. Call 1-844-575-8241 (TTY: 711) for ...Many UPMC for Life plans have adenine Flex Spend Memory that gives members health care dollars to spend on covered over-the-counter (OTC) products or dental, vision, and hearing services. Many UPMC for Life plans have a Flex Expenditure Card that gives elements health care dollars to spend on covered over-the-counter (OTC) products or …We would like to show you a description here but the site won't allow us.Jan 1, 2024 · the UPMC . for Life. Flex Spend Card under Extra Benefits and Services for more details. Vision services. 4. Medicare-covered: $30 per visit; $0 for one routine vision exam and one contact lens fitting exam every year Medicare-covered: $40 per visit; 30% of the cost for one routine vision exam and one contact lens fitting exam every year . IN/OUT:Security, value, or user by UPMC for Life. Understanding Medicare. Find everything you need the learn about Medicare, including information on when you are eligible, which four parts of Medicare, and how to enroll. Get Related Insight Medicare Learn about are extra benefits plus products.If you have good or excellent credit, then you can feel confident that companies are offering you the best interest rate credit card they have. You have a solid credit history and ...Credit cards used to just offer flexibility when you needed to pay for something before payday but now they can be used as a reward card offering cash back or air miles every time ...Many UPMC for Life plans have adenine Flex Spend Memory that gives members health care dollars to spend on covered over-the-counter (OTC) products or dental, vision, and hearing services. Many UPMC for Life plans have a Flex Expenditure Card that gives elements health care dollars to spend on covered over-the-counter (OTC) products or teeth ...Online Original Medicare, look in your current "Medicare & You" handbook that you received in the fall. You can view it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call. Member IDCard. 1-877-486-2048.

View the latest changes and additions to the UMPC Health Plan Flex Spend Card Catalog for 2023. Find out which items are eligible for reimbursement and how to submit claims online.

Here it is — the most-comprehensive eligibility list available on the web. From A to Z, items and services deemed eligible for tax-free spending with your Flexible Spending Account (FSA), Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) and more, complete with details and requirements.The UPMC Consumer Advantage Card lets you electronically access the pretax contribution you set aside in your health care flexible spending account. In most cases, there are no claim forms to complete and file. Your current balance and other account information are available on the UPMC Consumer Advantage Portal.Do you want to make your bathroom safer and more comfortable? If you are a UPMC for Life member, you can browse our 2024 Home Safety Product Catalog and order up to six items per year at no additional cost. Flipsnack player lets you view the catalog online and easily place your order. Don't miss this opportunity to improve your quality of life at home.Published March 16, 2023. Even though it is called a Medicare flex card, this prepaid debit card is issued by Medicare Advantage plans, not the U.S. government. It's offered through some — not all — private Medicare Advantage plans to help pay for specific expenses, such as over-the-counter (OTC) medications, a grocery allowance for ...Quick steps to complete and e-sign Upmc for life otc catalog 2023 online: Use Get Form or simply click on the template preview to open it in the editor. Start completing the fillable fields and carefully type in required information. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes.If you’re already a member, here are three easy ways to order your health and wellness kit: Call 1-888-356-5009 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. Have your UPMC for Life member ID card and date of birth ready. Log in to U PMC Health Plan Member Site. Under Better Health and Wellnes s on the homepage, click on Health and ...Catalogs are sent through the Converge fulfillment website. By calling Convey toll-free: 1-800-688-2515 (TTY: 711) from 8 a.m. to 11 p.m. Covered retail products and the mail order catalog can be found at: upmchp.us/flex-spend-card. Members can look up their card balance by:

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Our broad pharmacy network of more than 30,000 retail chain and independent pharmacies includes CVS/pharmacy, Giant Eagle, Rite Aid, Target, Walmart, and Wegmans (Erie locations). Step 1: Find your type of health insurance in this column. Step 2: Select your specific pharmacy benefit program from this column. Employer-sponsored (for non-retirees):This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal.Online Original Medicare, look in your current “Medicare & You” handbook that you received in the fall. You can view it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call. Member IDCard. 1-877-486-2048.Many UPMC for Life plans have a Flex Spend Card that giving our health care dollars to spend on covers over-the-counter (OTC) choose oder dental, vision, and hearing services. Many UPMC for Life plans have a Float Pass Card that gives personnel health care dollars to spend on covered over-the-counter (OTC) products or tooth, vision, furthermore …The UPMC Consumer Advantage Card lets you electronically access the pretax contribution you set aside in your health care flexible spending account. In most cases, there are no claim forms to complete and file. Your current balance and other account information are available on the UPMC Consumer Advantage Portal.Many UPMC for Life plans take a Flex Spend Card that gives members health care dollars until expense on covered over-the-counter (OTC) related or tooth, mission, and hearing services. Lots UPMC for Life plans have an Float Spent Card is gives members health care dollars to spend on covered over-the-counter (OTC) products alternatively dental, …Our plans include important extra benefits like vision including contacts or glasses, dental, and a great discount on hearing aids. Plus, you can choose a pl...Username. Password. Log In. Sign Up Forgot Username? Forgot Password? View UPMC's other Patient Portals. If you need help with your account, please call. 1-866-884-8579. Log in to your MyUPMC account.UPMC required Life Completing Care Sell Good Bill allows SNP members to shop covered over-the-counter merchandise and medical foodstuffs. Learn how to use your Shop Healthy Card! UPMC for Life Complete Care Shop Healthy Card allows SNP members to buy covered over-the-counter products and health groceries.Many UPMC for Life plans have a Flex Spend Card that giving our health care dollars to spend on covers over-the-counter (OTC) choose oder dental, vision, and hearing services. Many UPMC for Life plans have a Float Pass Card that gives personnel health care dollars to spend on covered over-the-counter (OTC) products or tooth, vision, furthermore ... ….

2 28. UPMC for Life Complete Care (HMO SNP) Home Safety Products Catalog. Home Safety Products Catalog. Made with FlippingBook. RkJQdWJsaXNoZXIy NDMwNTU=. Get access to benefits that can help you live safely and independently at home. View this catalog to see the products available to you.We would like to show you a description here but the site won't allow us.Contact the Center for Audiology and Hearing Aids. For testing or to make an appointment, please call. 412-647-2100. View our list of Audiology Center locations. Learn about the different types of hearing aids available to patients at the UPMC Center for Audiology and Hearing Aids. Schedule an appointment today.Starting Jan. 1, the UPMC for Life Complete Care (HMO SNP) Shop Healthy Card will give members a $500 quarterly allowance —that's $2,000 per year—to spend on covered over-the-counter (OTC) products, healthy foods, pet care supplies, pest control, and household utilities. Shop the UPMC for Life Complete Care plan in your area.Military Star cards are accepted at Army and Air Force exchanges, Marine Corps exchanges, Navy exchanges, Coast Guard exchanges, and exchange catalogs. Additionally, online sites a...Oct 6, 2022 · UPMC Health Plan today announced its 2023 UPMC for Life Medicare Advantage (MA) offerings and highlighted several new resources to meet seniors’ needs while keeping health care affordable—like flexible spending cards for over-the-counter (OTC) necessities and dental, vision and hearing services. Medicare’s annual open enrollment begins Oct. 15 and ends Dec. 7. During this time, Medicare ...Your UPMC for Life Flex Spend Card gives you health care dollars to spend however you like on over-the-counter (OTC) products and dental, vision, and hearing services. Now you can use your card on medical service costs like doctor's office copays too! 1 Here's what's new and improved for 2024! Your health care coverage should make sense ...In this digital age, print catalogs may seem like a waste of paper. They clutter up our mailboxes and kitchen tables before inevitably ending up in the trash. But companies continu...UPMC required Life Completing Care Sell Good Bill allows SNP members to shop covered over-the-counter merchandise and medical foodstuffs. Learn how to use your Shop Healthy Card! UPMC for Life Complete Care Shop Healthy Card allows SNP members to buy covered over-the-counter products and health groceries.UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. If you are a provider, please call Provider Services at 1-866-918-1595. UPMC for Life Complete Care members can call 1-800-606-8648 (TTY: 711), 24 hours a day, 7 days a week. Upmc for life flex spend card catalog, Manage appointments, communicate with your doctor, pay bills, renew prescriptions, and view your medical records and lab results with MyUPMC., Nursing pads, breast pumps, milk storage bags. Baby bottles, sippy cups, and pacifiers. Nasal aspirators, bulb syringes, nasal saline spray. Baby care accounts for around 5% of FSA spending, while child dental care is another 3% [2]. And don't forget - over-the-counter kids' medicines are also FSA-eligible., ShopShop - Flex Spend Card | UPMC for Life - UPMC Health Plan 5. Documents and FormsUPMC for Life HMO/PPO members can call our Member Services Department at 1 … 6. 2024 Medicare Flex Spend C…2024 Medicare Flex Spend Card Catalog - Flex Spend Card | UPMC for Life - … 7. Medicare ProgramThis information is available for free in other languages., UPMC for Life HMO/PPO members can call our Member Services Department at 1-877-539-3080 (TTY: 711) seven days a week from 8 a.m. to 8 p.m. If you are a provider, please call Provider Services at 1-866-918-1595. UPMC for Life Complete Care members can call 1-800-606-8648 (TTY: 711), 24 hours a day, 7 days a week., Many UPMC for Lived plans hold a Turn Spend Maps that gives members human care dollars to use on covered over-the-counter (OTC) products or dentist, vision, and sound services. Many UPMC for Life layout have a Flex Expenditure Card that gives members health care dollars to spend on covered over-the-counter (OTC) commodity or dental, vision, and ..., https://ssl.qz.com/brief What to watch for today The aftermath of Typhoon Noul. The strongest storm to hit the Philippines so far this year, Noul made landfall on Sunday, and was e..., Other physicians/providers are available in the UPMC for Life network. This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plans have a contract with the PA State Medical ..., Our broad pharmacy network of more than 30,000 retail chain and independent pharmacies includes CVS/pharmacy, Giant Eagle, Rite Aid, Target, Walmart, and Wegmans (Erie locations). Step 1: Find your type of health insurance in this column. Step 2: Select your specific pharmacy benefit program from this column. Employer-sponsored (for non-retirees):, On average, human beings spend 33 percent of their lives sleeping, according to Sleep Disorders and Sleep Deprivation. This amounts to about eight hours per day. While not everythi..., 2023 UPMC for Life plans. UPMC for Life is proud to offer a variety of high-quality, affordable Medicare plans for the upcoming year. Our plans help Medicare beneficiaries get easy access to the care they need with important extra benefits and outstanding customer service. Now you have more opportunities to grow your book of business than ever ..., Learn more about the Medicare Advantage plans that include a healthy food allowance (formally healthy food card): Eligible members get a grocery allowance. Buy healthy food online or in person. Shop at plan-approved stores like Walgreens, Walmart, CVS, Kroger. Some plans may cover meal delivery services., the UPMC . for Life. Flex Spend Card under Extra Benefits and Services for more details. Vision services. 4. Medicare-covered: $35 per visit; $0 for one routine vision exam and one contact lens fitting exam every year Medicare-covered: $45 per visit; 30% of the cost for one routine vision exam and one contact lens fitting exam every year . IN/OUT:, Schedule Your Mammogram Through Your UPMC Patient Portal. Sign in to your UPMC patient portal account to make your mammogram appointment. It's secure and easy with just a few simple steps! No need to call or talk to a live person. Choose a date, time, and location that works for you! Patients can also schedule appointments by phone by calling ..., Oct 26, 2023 · UPMC for Life Flex Spend Card—your health care dollars, now with more choice! The UPMC f or Life Flex Spend Card gives you health care dollars to spend however you like on over-the-counter (OTC) products and dental, vision, and hearing services. S tarting Jan. 1, you can use your card on medical service costs like doctor’s offic e copays too!, The UPMC Consumer Advantage Card lets you electronically access the pretax contribution you set aside in your health care flexible spending account. In most cases, there are no claim forms to complete and file. Your current balance and other account information are available on the UPMC Consumer Advantage Portal., If you need help with your account, please call 1-866-884-8579.., Find the best Upmc Flex Card Online Catalog, Find your favorite catalogs from the brands you love at fresh-catalog.com. Home. ... 2023 · UPMC for Life Flex Spend Card and Over-the-Counter (OTC) Mail-Order Catalog Your health care dollars, your choice! 202 3 5103 1234 5678 9010 GOOD ..., UPMC for Life Flex Spend Card UPMC Health Plan. Preview 833-647-9633. 6 hours ago WebJun 5, 2023 · • You must activate and sign your card to start using it Call 1-833-647-9633 and follow the prompts You will be asked to enter your 16-digit Flex Spend Card …. 1.Flex Spend Card UPMC for Li…The UPMC for Life Flex Spend Card gives members health care dollars to spe…, Your UPMC for Life Flex Spend Card gives you health care dollars to spend however you like on over-the-counter (OTC) products and dental, vision, and hearing services. Now you can use your card on medical service costs like doctor's office copays too! 1 Here's what's new and improved for 2024! Your health care coverage should make sense ..., WebJun 5, 2023 · UPMC for Life Flex Spend Card and Over-the-Counter (OTC) Mail-Order Catalog Your health care dollars, your choice! 202 3 5103 1234 5678 9010 GOOD … See Also: Upmc flex spend card catalog 2024 Show details . Flex Spend Card UPMC for Life UPMC Health Plan. Preview., DataPath Administrative Services has been providing professional third-party administration for employee benefit plans (FSA, DCAP, HRA, HSA, Transit, COBRA and more) since 1996. Tax-advantaged benefit accounts can't be used for regular food purchases. But some nutritional supplements and alternatives can. Learn more!, Do you want to make your bathroom safer and more comfortable? If you are a UPMC for Life member, you can browse our 2024 Home Safety Product Catalog and order up to six items per year at no additional cost. Flipsnack player lets you view the catalog online and easily place your order. Don't miss this opportunity to improve your quality of life at home., Published March 16, 2023. Even though it is called a Medicare flex card, this prepaid debit card is issued by Medicare Advantage plans, not the U.S. government. It's offered through some — not all — private Medicare Advantage plans to help pay for specific expenses, such as over-the-counter (OTC) medications, a grocery allowance for ..., UPMC Consumer Advantage Member Services representatives are available at 1-855-492-8762 Monday through Friday from 7 a.m. through 7 p.m. and Saturday from 8 a.m. through 3 p.m. You can also email your questions to [email protected]. Get familiar with your UPMC Health Plan Take a Healthy Step Federal Employee Health Benefits health ..., ShopShop - Flex Spend Card | UPMC for Life - UPMC Health Plan 5. Documents and FormsUPMC for Life HMO/PPO members can call our Member Services Department at 1 … 6. 2024 Medicare Flex Spend C…2024 Medicare Flex Spend Card Catalog - Flex Spend Card | UPMC for Life - … 7. Medicare ProgramThis information is available for …, UPMC for Life PPO Flex Rx (PPO) is a Medicare Advantage (Part C) Plan by UPMC for Life. Premium: $0. Enroll Now. This page features plan details for 2022 UPMC for Life PPO Flex Rx (PPO) H5533 - 011 - 0 available in Lehigh Capital. IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:, If you’re an avid angler or simply enjoy spending time in the great outdoors, then you’re likely familiar with the Pro Bass Shop. Known for their extensive selection of fishing gea..., UPMC Health Plan, The FSA Store carries over 2,500+ guaranteed FSA-eligible products, health essentials, and more. Skip to main ... Spend $50 to get free shipping. Earn Rewards. View Perks dashboard or enroll now. Menu Cold & Allergy Surprisingly Eligible Bundles Browse; Brand Shop All Brands A-Z, There are many reasons to choose UPMC Consumer Advantage. Review our comparison chart to see which are right for you. Compare Spending Accounts. View Blog. UPMC Consumer Advantage offers FSA, HSA, HRA, and QTA options. Learn more about what each plan offers and how they differ from each other., All UPMC for Life Complete Care members, who often have lower incomes, live in communities impacted by health disparities, and have multiple medically complex, chronic conditions, will receive a UPMC for Life Complete Care Shop Healthy Card. Using the card, members can spend $1,600 in 2023 ($400 per quarter) on OTC products and healthy foods., Do you want to make your bathroom safer and more comfortable? If you are a UPMC for Life member, you can browse our 2024 Home Safety Product Catalog and order up to six items per year at no additional cost. Flipsnack player lets you view the catalog online and easily place your order. Don't miss this opportunity to improve your quality of life at home., • UPMC Health Benefits members should send this completed claim form and itemized bills to: UPMC Dental Advantage Claims Department P.O. Box 1600 Pittsburgh, PA 15230-1600 To be completed by subscriber 1.Patient Information Patient First Name Middle Last Relationship to Subscriber Self Child Spouse Other Sex Male Female Married Yes