Provider forms
Health care professionals can access forms for UnitedHealthcare plans, including commercial, Medicaid, Medicare and Exchange plans in one convenient location.
Easily access and download all UnitedHealthcare provider-forms in one convenient location.
Save time – Go digital
The UnitedHealthcare Provider Portal allows you to submit referrals, prior authorizations, claims, claim reconsideration and appeals, demographic changes and more.
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 Request Form Complete online | PDF
- New Jersey DOBI Healthcare Provider Application (Commercial) PDF
- New Jersey DOBI Healthcare Provider Application (Oxford) PDF
Exception Requests
- Contraceptive Exception Form PDF
- Colorado Standard Exemption 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
Prior authorization
Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations 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 - Healthcare 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
- Appointment of Representative Form
- Corrected Claim and Claim Reconsideration Request Form Complete online | PDF
- Chronic Condition Verification for C-SNPs - Cover Letter
- Chronic Condition Verification for C-SNPs - Verification Form
- Medicare Direct PFFS Uncollectible Bad Debt Submittal Form
- Skilled Nursing Facilities Clinical and Therapy Request Form
- Special Supplemental Benefits for the Chronically Ill (SSBCI) Verification for D-SNPs and IE-SNPs - Cover Letter
- Special Supplemental Benefits for the Chronically Ill (SSBCI) Verification for D-SNPs and IE-SNPs - Verification Form
Other
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 Complete online | PDF
Other
- Appointment of Representative Form
- Telephone Consumer Protection Act (TCPA) Opt out | Opt in
State-specific pharmacy prior authorization forms
State-specific forms - General
- Arizona
- Colorado
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Indiana
- Kansas
- Kentucky
- Louisiana
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Nebraska
- New Jersey
- New Mexico
- New York
- North Carolina
- Ohio
- Oklahoma
- Rhode Island
- Tennessee
- Texas
- Virginia
- Washington
- Wisconsin
Claims and payments
- New Jersey DOBI Healthcare Provider Application PDF
Pharmacy prior authorization
- Alabama Prior Authorization Form for Prescription Benefits Complete online | PDF
- 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 Complete online | PDF
- Louisiana Prior Authorization Form for Prescription Benefits
- Maryland Prior Authorization Form for Prescription Benefits Complete online | PDF
- Massachusetts Prior Authorization Form for Prescription Benefits
- Michigan Prior Authorization Form for Prescription Benefits
- Mississippi Prior Authorization Form for Prescription Benefits Complete online | PDF
- Missouri Prior Authorization Form for Prescription Benefits
- Nebraska Prior Authorization Form - Prescription Drug DME PDF
- Nevada Prior Authorization Form for Prescription Benefits Complete online | PDF
- New York Prior Authorization Form for Prescription Benefits Complete online | PDF
- North Carolina Prior Authorization Form for Prescription Benefits Complete online | PDF
- Ohio Prior Authorization Form for Prescription Benefits Complete online | PDF
- Oklahoma Prior Authorization Form for Prescription Benefits Complete online | PDF
- Tennessee Prior Authorization Form for Prescription Benefits Complete online | PDF
- Texas Prior Authorization Form for Prescription Benefits
- Virginia Prior Authorization Form for Prescription Benefits Complete online | PDF
- Washington Prior Authorization Form for Prescription Benefits Complete online | PDF
General
- Colorado Rocky Mountain Health Plan Out of Network Request form
- Colorado Rocky Mountain Health Plan Release of Information form
- Colorado Rocky Mountain Health Plan Release of Information form - Spanish
- Colorado Serious Mental Illness Step Therapy Exception Form
- Designation of Authorized Representative Form
- Nebraska Prior Authorization Form - Healthcare Services
Other
- Commercial
- Medicare Advantage
- Community Plan (Medicaid)
- Individual Exchange
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 Request Form Complete online | PDF
- New Jersey DOBI Healthcare Provider Application (Commercial) PDF
- New Jersey DOBI Healthcare Provider Application (Oxford) PDF
Exception Requests
- Contraceptive Exception Form PDF
- Colorado Standard Exemption 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
Prior authorization
Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations 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 - Healthcare 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
- Appointment of Representative Form
- Corrected Claim and Claim Reconsideration Request Form Complete online | PDF
- Chronic Condition Verification for C-SNPs - Cover Letter
- Chronic Condition Verification for C-SNPs - Verification Form
- Medicare Direct PFFS Uncollectible Bad Debt Submittal Form
- Skilled Nursing Facilities Clinical and Therapy Request Form
- Special Supplemental Benefits for the Chronically Ill (SSBCI) Verification for D-SNPs and IE-SNPs - Cover Letter
- Special Supplemental Benefits for the Chronically Ill (SSBCI) Verification for D-SNPs and IE-SNPs - Verification Form
Other
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 Complete online | PDF
Other
- Appointment of Representative Form
- Telephone Consumer Protection Act (TCPA) Opt out | Opt in
State-specific pharmacy prior authorization forms
State-specific forms - General
- Arizona
- Colorado
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Indiana
- Kansas
- Kentucky
- Louisiana
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Nebraska
- New Jersey
- New Mexico
- New York
- North Carolina
- Ohio
- Oklahoma
- Rhode Island
- Tennessee
- Texas
- Virginia
- Washington
- Wisconsin
Claims and payments
- New Jersey DOBI Healthcare Provider Application PDF
Pharmacy prior authorization
- Alabama Prior Authorization Form for Prescription Benefits Complete online | PDF
- 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 Complete online | PDF
- Louisiana Prior Authorization Form for Prescription Benefits
- Maryland Prior Authorization Form for Prescription Benefits Complete online | PDF
- Massachusetts Prior Authorization Form for Prescription Benefits
- Michigan Prior Authorization Form for Prescription Benefits
- Mississippi Prior Authorization Form for Prescription Benefits Complete online | PDF
- Missouri Prior Authorization Form for Prescription Benefits
- Nebraska Prior Authorization Form - Prescription Drug DME PDF
- Nevada Prior Authorization Form for Prescription Benefits Complete online | PDF
- New York Prior Authorization Form for Prescription Benefits Complete online | PDF
- North Carolina Prior Authorization Form for Prescription Benefits Complete online | PDF
- Ohio Prior Authorization Form for Prescription Benefits Complete online | PDF
- Oklahoma Prior Authorization Form for Prescription Benefits Complete online | PDF
- Tennessee Prior Authorization Form for Prescription Benefits Complete online | PDF
- Texas Prior Authorization Form for Prescription Benefits
- Virginia Prior Authorization Form for Prescription Benefits Complete online | PDF
- Washington Prior Authorization Form for Prescription Benefits Complete online | PDF
General
- Colorado Rocky Mountain Health Plan Out of Network Request form
- Colorado Rocky Mountain Health Plan Release of Information form
- Colorado Rocky Mountain Health Plan Release of Information form - Spanish
- Colorado Serious Mental Illness Step Therapy Exception Form
- Designation of Authorized Representative Form
- Nebraska Prior Authorization Form - Healthcare Services