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P Claims Transmittal Form Z6240 R0414 doc

P Claims Transmittal Form Z6240 R0414 doc 2025

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The document is a Claim Transmittal Form from The Prudential Insurance Company of America, administered by Concentrix Insurance Solutions. It is used for submitting claims when standardized forms are not available. The form requires detailed information about the insured, patient, and claim specifics, including authorization for the release of medical information and payment instructions. It also includes a certification statement regarding the accuracy of the provided information and outlines potential penalties for fraudulent claims.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (62 Votes)
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