Provider forms

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 for, you 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