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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.

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

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
  • District of Columbia Transition of Prior Authorization form for Surest plans PDF
  • District of Columbia Transition of Prior Authorization form for UHC plans PDF
  • Empire Plan Predetermination Form PDF
  • Georgia Transition of Prior Authorization form for Surest plans PDF
  • Georgia Transition of Prior Authorization form for UHC plans 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
  • Minnesota Transition of Prior Authorization form for Surest plans PDF
  • Minnesota Transition of Prior Authorization form for UHC plans PDF
  • Mississippi Transition of Prior Authorization form for Surest plans PDF
  • Mississippi Transition of Prior Authorization form for UHC plans 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 Jersey Transition of Prior Authorization form for UHC plans PDF
  • New Mexico Prior Authorization Form  Complete online | PDF
  • Oklahoma Transition of Prior Authorization form for Surest plans PDF
  • Oklahoma Transition of Prior Authorization form for UHC plans 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
  • Washington Transition of Prior Authorization form for UHC plans PDF
  • West Virginia Pre-Determination Form  Complete online
  • West Virginia Transition of Prior Authorization form for Surest plans PDF
  • West Virginia Transition of Prior Authorization form for UHC plans PDF
  • Wyoming Transition of Prior Authorization form for UHC plans PDF

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.

Pharmacy prior authorization

General

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
  • District of Columbia Transition of Prior Authorization form for Surest plans PDF
  • District of Columbia Transition of Prior Authorization form for UHC plans PDF
  • Empire Plan Predetermination Form PDF
  • Georgia Transition of Prior Authorization form for Surest plans PDF
  • Georgia Transition of Prior Authorization form for UHC plans 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
  • Minnesota Transition of Prior Authorization form for Surest plans PDF
  • Minnesota Transition of Prior Authorization form for UHC plans PDF
  • Mississippi Transition of Prior Authorization form for Surest plans PDF
  • Mississippi Transition of Prior Authorization form for UHC plans 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 Jersey Transition of Prior Authorization form for UHC plans PDF
  • New Mexico Prior Authorization Form  Complete online | PDF
  • Oklahoma Transition of Prior Authorization form for Surest plans PDF
  • Oklahoma Transition of Prior Authorization form for UHC plans 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
  • Washington Transition of Prior Authorization form for UHC plans PDF
  • West Virginia Pre-Determination Form  Complete online
  • West Virginia Transition of Prior Authorization form for Surest plans PDF
  • West Virginia Transition of Prior Authorization form for UHC plans PDF
  • Wyoming Transition of Prior Authorization form for UHC plans PDF

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.

Pharmacy prior authorization

General