UHG Request to Reopen

1
Service Provider Name* This field is required.
2
Email* This field is required.Email of the person submitting this request. This is where responses will be sent.
example@example.com
3
Email
example@example.com
4
Client Account IDThe UHG Account ID
5
UHG Account ID* This field is required.Exactly as it was placed in your office.
6
Date Account Was Closed & Returned from your office* This field is required.
7
Service Provider Notes* This field is required.You may not collect on any closed account until UHG provides permission to reopen the account.
Provide a reason this account should be placed back with your office.
8
UHG Comments-Internal
Huge
Large
Normal
Small
Ok
Ok
9
Get Page URL
Should be Empty: