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 Request Form  Complete online | 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
• Option Care Health Medication Prescriber Order Form  PDF 
  
• Skilled Nursing Facilities Clinical and Therapy Request Form  PDF
  

Our network

• Demographic Change Form  Complete online
• Provider Termination for Cause Appeal Form PDF
• Provider Termination Without Cause Appeal Form PDF

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 | PDF
• 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 | PDF
• 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
  
• 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
  
• Nevada Medical Standard Prior Authorization Form  Complete online | PDF
• New Hampshire Prescription Prior Authorization Form  PDF
  
• New Mexico Prior Authorization Form  Complete online | PDF
• Oregon Commercial Plan Prescription Prior Authorization Form  Complete online | PDF | 
• Tennessee Transition of Prior Authorization form for Surest plans PDF
  
• Tennessee Transition of Prior Authorization form for UHC plans PDF
• Texas Commercial Prior Authorization Form  PDF
• West Virginia Pre-Determination Form  Complete online