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Provider forms

Health care professionals can access forms for UnitedHealthcare plansincluding commercialMedicaidMedicare and Exchange plans in one convenient location.

Easily access and download UnitedHealthcare provider forms in one location.

Select plan type

If your select says “Complete in portal”you can skip the PDF form and complete the action online in the UnitedHealthcare Provider Portal.

Claims and payments

  • Claims overpayment refund form  PDF 
  • Corrected claim and claim reconsideration form  Complete online | PDF
  • New Jersey DOBI health care provider application (commercial)  PDF
  • New Jersey DOBI health care provider application (Oxford)  PDF

Exception requests

  • Contraceptive exception form  PDF
  • Colorado standard cxemption form for contraceptive products  Complete online 
  • New York contraceptive exception request form  Complete online | PDF

Other

  • Colorado serious mental illness step therapy exception form  PDF
  • Confidential exchange of information form  PDF
  • Commercial designation of authorized representative form  Complete online | PDF
  • New York Empire Plan predetermination request form  PDF
  • Option Care Health medication prescriber order form  PDF 
  • Skilled nursing facilities clinical and therapy request form  PDF
  • Telephone Consumer Protection Act (TCPA)  Opt out | Opt in

Our network

  • Provider termination for cause appeal form  PDF
  • Provider termination without cause appeal form  PDF

Prior authorization

If you don't see the form you're looking foryou can complete the prior authorization online. 

  • Arizona health care services prior authorization form  Complete online | PDF
  • Arizona prior authorization medications DME medical devices form  Complete online
  • California prescription drugs prior authorization form  Complete online | PDF
  • Colorado prescription prior authorization form  Complete online | PDF
  • Empire Plan predetermination form  PDF
  • Illinois prescription drugs prior authorization request form   Complete online | PDF
  • Indiana prescription prior authorization form   Complete online
  • Louisiana prescription prior authorization form   Complete online | PDF
  • Massachusetts cardiac imaging prior authorization request form   Complete online | PDF
  • Massachusetts chemotherapy supportive care prior authorization request form   Complete online | PDF
  • Massachusetts hepatitis medication prior authorization request form   Complete online | PDF
  • Massachusetts non-OB ultrasound request form  Complete online | PDF
  • Massachusetts PET CT request form  Complete online | PDF
  • Massachusetts prescription prior authorization form   PDF
  • Massachusetts Synagis® prior authorization request form  Complete online | PDF 
  • Michigan prescription drug prior authorization form FIS 2288  PDF
  • National transfer of prior authorization form for UnitedHealthcare plans  PDF
  • National transfer of prior authorization form for Surest plans  PDF
  • Nebraska prior authorization form - prescription drug DME  PDF
  • Nebraska prior authorization form - health care services  PDF
  • Network prior authorization gap exception request form  Complete online | PDF 
  • Nevada cancer stage 3 or 4 step therapy protocol prior authorization exception form  Complete online | PDF
  • New Hampshire prescription prior authorization form  PDF
  • New Mexico prescription prior authorization form  PDF
  • Oregon commercial plan prescription prior authorization form  Complete online | PDF
  • Texas commercial prior authorization form  PDF
  • West Virginia pre-determination form  Complete online

Other

To learn more about Medicare Part D prescription drug coverage or to access related formsreview the materials available on the Plan information and forms page of UHC.com/medicare.

Claims and payments

Other

Pharmacy prior authorization

General

Claims and payments

  • New Jersey DOBI health care provider application PDF

Pharmacy prior authorization

General

Other

If your select says “Complete in portal”you can skip the PDF form and complete the action online in the UnitedHealthcare Provider Portal.

Claims and payments

  • Claims overpayment refund form  PDF 
  • Corrected claim and claim reconsideration form  Complete online | PDF
  • New Jersey DOBI health care provider application (commercial)  PDF
  • New Jersey DOBI health care provider application (Oxford)  PDF

Exception requests

  • Contraceptive exception form  PDF
  • Colorado standard cxemption form for contraceptive products  Complete online 
  • New York contraceptive exception request form  Complete online | PDF

Other

  • Colorado serious mental illness step therapy exception form  PDF
  • Confidential exchange of information form  PDF
  • Commercial designation of authorized representative form  Complete online | PDF
  • New York Empire Plan predetermination request form  PDF
  • Option Care Health medication prescriber order form  PDF 
  • Skilled nursing facilities clinical and therapy request form  PDF
  • Telephone Consumer Protection Act (TCPA)  Opt out | Opt in

Our network

  • Provider termination for cause appeal form  PDF
  • Provider termination without cause appeal form  PDF

Prior authorization

If you don't see the form you're looking foryou can complete the prior authorization online. 

  • Arizona health care services prior authorization form  Complete online | PDF
  • Arizona prior authorization medications DME medical devices form  Complete online
  • California prescription drugs prior authorization form  Complete online | PDF
  • Colorado prescription prior authorization form  Complete online | PDF
  • Empire Plan predetermination form  PDF
  • Illinois prescription drugs prior authorization request form   Complete online | PDF
  • Indiana prescription prior authorization form   Complete online
  • Louisiana prescription prior authorization form   Complete online | PDF
  • Massachusetts cardiac imaging prior authorization request form   Complete online | PDF
  • Massachusetts chemotherapy supportive care prior authorization request form   Complete online | PDF
  • Massachusetts hepatitis medication prior authorization request form   Complete online | PDF
  • Massachusetts non-OB ultrasound request form  Complete online | PDF
  • Massachusetts PET CT request form  Complete online | PDF
  • Massachusetts prescription prior authorization form   PDF
  • Massachusetts Synagis® prior authorization request form  Complete online | PDF 
  • Michigan prescription drug prior authorization form FIS 2288  PDF
  • National transfer of prior authorization form for UnitedHealthcare plans  PDF
  • National transfer of prior authorization form for Surest plans  PDF
  • Nebraska prior authorization form - prescription drug DME  PDF
  • Nebraska prior authorization form - health care services  PDF
  • Network prior authorization gap exception request form  Complete online | PDF 
  • Nevada cancer stage 3 or 4 step therapy protocol prior authorization exception form  Complete online | PDF
  • New Hampshire prescription prior authorization form  PDF
  • New Mexico prescription prior authorization form  PDF
  • Oregon commercial plan prescription prior authorization form  Complete online | PDF
  • Texas commercial prior authorization form  PDF
  • West Virginia pre-determination form  Complete online

Other

To learn more about Medicare Part D prescription drug coverage or to access related formsreview the materials available on the Plan information and forms page of UHC.com/medicare.

Claims and payments

Other

Pharmacy prior authorization

General

Claims and payments

  • New Jersey DOBI health care provider application PDF

Pharmacy prior authorization

General

Other