Provider forms

Claims and payments

• Claims Overpayment Refund Form
• Corrected Claim and Claim Reconsideration Request Form

Exception Requests

• Colorado Standard Exemption Form for Contraceptive Products
• New York Contraceptive Exception Request Form

Other

• Confidential Exchange of Information Form
• Commercial Designation of Authorized Representative Form
• Option Care Health Medication Prescriber Order Form 
  
• Skilled Nursing Facilities Clinical and Therapy Request Form
  

Our network

• Demographic Change Form

Prior authorization

Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations online.

• Arizona Health Care Services Prior Authorization Form
• Arizona Prior Authorization Medications DME Medical Devices Form
• Arkansas, Iowa, Illinois, Mississippi, Oklahoma, Virginia, West Virginia Prescription Prior Authorization Form
• California Prescription Prior Authorization Form
• Colorado Prescription Prior Authorization Form
• Fertility Solutions Prior Authorization Request Form
  
• Illinois Prescription Drugs Prior Authorization Request Form
• Indiana Prescription Prior Authorization Form
• Louisiana Prescription Prior Authorization Form
• Massachusetts Cardiac Imaging Prior Authorization Request Form
  
• Massachusetts Chemotherapy Supportive Care Prior Authorization Request Form
• Massachusetts Hepatitis Medication Prior Authorization Request Form
• Massachusetts Non-OB Ultrasound Request Form
• Massachusetts PET CT Request Form
• Massachusetts Prescription Prior Authorization Form
• Massachusetts Synagis® Prior Authorization Request Form
• Michigan Prescription Drug Prior Authorization Form FIS 2288
  
• Network Prior Authorization Gap Exception Request Form
• Nevada Cancer Stage 3 or 4 Step Therapy Protocol Prior Authorization Exception Form
  
• Nevada Medical Standard Prior Authorization Form
• New Hampshire Prescription Prior Authorization Form
  
• New Mexico Prior Authorization Form
• New York Prior Authorization Predetermination Form
• Oregon Commercial Plan Prescription Prior Authorization Form
• Texas Commercial Prior Authorization Form
• Texas Surest Prescription Prior Authorization Form

• Corrected Claim and Claim Reconsideration Request Form
  
• Demographic Change Form
• Medicare Direct PFFS Uncollectible Bad Debt Submittal Form
  
• Skilled Nursing Facilities Clinical and Therapy Request Form
  

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

Claims and payments

• Corrected Claim and Claim Reconsideration Request Form

Our network

• Demographic Change Form

State-specific pharmacy prior authorization forms

• Community Plan Pharmacy Prior Authorization for Prescribers

State-specific forms - General

• Arizona
• California
• Colorado
• Delaware
• District of Columbia
• Florida
• Georgia
• Hawaii
• Indiana
• Iowa
• Kansas
• Kentucky
• Louisiana
• Maryland
• Massachusetts
• Michigan
• Minnesota
• Mississippi
• Missouri
• Nebraska
• New Jersey
• New York
• North Carolina
• Ohio
• Oklahoma
• Rhode Island
• Tennessee
• Texas
• Virginia
• Washington
• Wisconsin

Our network

• Demographic Change Form

Pharmacy prior authorization

• Alabama Prior Authorization Form for Prescription Benefits
  
• Arizona Prior Authorization Form for Prescription Benefits
• Colorado Prior Authorization Form for Prescription Benefits
• Florida Prior Authorization Form for Prescription Benefits
• Georgia Prior Authorization Form for Prescription Benefits
• Illinois Prior Authorization Form for Prescription Benefits
• Kansas Prior Authorization Form for Prescription Benefits
• Louisiana Prior Authorization Form for Prescription Benefits
• Maryland Prior Authorization Form for Prescription Benefits
• Massachusetts Prior Authorization Form for Prescription Benefits
• Michigan Prior Authorization Form for Prescription Benefits
• Mississippi Prior Authorization Form for Prescription Benefits
• Missouri Prior Authorization Form for Prescription Benefits
• Nevada Prior Authorization Form for Prescription Benefits
• New York Prior Authorization Form for Prescription Benefits
• North Carolina Prior Authorization Form for Prescription Benefits
• Ohio Prior Authorization Form for Prescription Benefits
• Oklahoma Prior Authorization Form for Prescription Benefits
• Tennessee Prior Authorization Form for Prescription Benefits
• Texas Prior Authorization Form for Prescription Benefits
• Virginia Prior Authorization Form for Prescription Benefits
• Washington Prior Authorization Form for Prescription Benefits