Forms
Find commonly used forms and documents
View the links below to find forms you can download, making it quicker to take action on claims, reimbursements and more.
Looking for other forms?
If you can’t find the form or document you’re looking for below, sign in to your member site to find more.
Download forms here
Form categories are listed in alphabetical order.
Choice, Choice Plus, Non-Differential ("Non-Diff" or "Options PPO"), Select and Select Plus, Core; Core Essentials Network, and Navigate continuity of care
- Dental claim form (online)
- Individual dental plan enrollment form (pdf)
- CA dental individual enrollment form (online)
- CA dental HMO individual plan change of status form (online)
- SignatureValue dental V160 brochure and enrollment form (pdf)
- Non-participating dentist nomination form (pdf)
- Clinical exception form
- New York State Personal Protective Equitement Charge Restriction Assistance (pdf)
Dental grievance and appeals
- Dental grievance form (English & Español combined) (pdf)
- CA DENTAL GRIEVANCE FORM (English & Español combined) (pdf)
- CA GRIEVANCE FORM FOR CANCELLATIONS, RECISSIONS AND NONRENEWALS OF AN ENROLLMENT OR SUBSCRIPTION (pdf)
- Kentucky complaint, grievance and appeals (pdf)
- Massachusetts external grievance review form English (pdf)
- Massachusetts external grievance review form Español (pdf)
How to file a claim
1. Choose the appropriate claim packet below.
2. Complete, sign and date the necessary forms in the packet.
3. Use the contact information on the form to fax or email your claim.
E-mail: fpcustomersupport@uhc.com
Fax: 1-888-505-8550
Phone: If you have any questions, please call our claims department at 1-888-299-2070, between 8 a.m. and 6 p.m. ET.
Claim form packets
Note: Not for members living in New York or California.
Disability insurance
Life insurance
Hospital indemnity protection plan
Critical illness protection plan
- Critical illness protection plan claim form packet (standard) (pdf)
- Critical illness protection plan claim form packet (enhanced) (pdf)
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Note: Use if your plan includes Child Critical Illness, Additional Critical Illness, or Partial Benefit Critical Illness benefit options. If you are not sure if your plan includes these benefits, please refer to your Certificate of Coverage or contact your employer.
Accident protection plan
Standalone authorization
- Standalone authorization form (pdf)
- Standalone personal representative form (pdf)
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These optional forms are used by the member to provide UnitedHealthcare with authorization to discuss their claim with someone other than the member.
Standalone direct deposit
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Standalone Direct Deposit form (pdf)
Note: Not for members living in New York.
This optional form is used by the member to request Direct Deposit be started for all Disability, Life and Supplemental Health benefit checks.
- Flexible Spending Account (FSA) request for health care reimbursement (pdf)
- Flexible Spending Account (FSA) request for dependent care reimbursement (pdf)
- Health Reimbursement Account (HRA) claim form (pdf)
- Health Savings Account (HSA) forms (online list)
- Sweat equity program for UnitedHealthcare NY small group (1–100) and NJ large group (51+) members (pdf)
- Sweat Equity Reimbursement Form for UnitedHealthcare NY Small Group (1–100) and NJ Large Group (51+) Members (online)
- Medical claim form – digital format (pdf)
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COVID-19 testing reimbursement form
Note: This form applies to those that have insurance through their employer or have an individual plan through UnitedHealthcare and log in through myuhc.com. This excludes members with plans from Oxford, Expat and Empire.
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International claim form
Note: This form applies to those that have insurance through their employer or have an individual plan through UnitedHealthcare and log in through myuhc.com. This excludes members with plans from Oxford, Expat and Empire.
- Oxford NJ, CT, and ASO (any state) medical claim form (pdf)
- Oxford NY medical claim form (pdf)
- PA medical claim form - digital format (pdf)
- Sweat Equity program for Oxford members (pdf)
- Sweat Equity reimbursement form for Oxford members (pdf)
- Oxford prescription mail-order form (pdf)
- Oxford prescription reimbursement claim form - English (pdf)
- Oxford prescription reimbursement claim form - Spanish (pdf)
- Oxford NJ, CT, and ASO (any state) medical claim form (pdf)
- Oxford NY medical claim form (pdf)
- Oxford NJ - Large Employer Member Enrollment/Change Request Form (pdf)
- Oxford NJ - Small Employer Member Enrollment/Change Request Form (pdf)
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Proof of Coverage and Proof of Lost Coverage Form
Use this form to request Proof of Coverage (POC) document(s) when coverage is still active or to request Proof of Lost Coverage (POLC) document(s) when coverage is no longer active.
This form is for individuals that currently have or previously had insurance through their employer or an individual plan through UnitedHealthcare and sign in using myuhc.com.
This form should not be used by UnitedHealthcare West, Oxford, Expat and Empire plan members.
California continuity of care forms for SignatureValue managed care members
California grievance forms for SignatureValue managed care members
Oklahoma, Oregon, Texas and Washington continuity of care form for SignatureValue managed care members
Disclaimers for Disability, life and supplemental insurance claim forms
Note about email: We cannot guarantee the security of any communication transmitted through the internet. We are not liable for the illegal acts of third parties such as criminal hackers. Please use your best judgment when deciding how to email your information. We can accept emails sent with or without encryption.
UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products in California by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX(05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL(05/03) and UHCLD-POL 2/2008. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT and Unimerica Life Insurance Company is located in Milwaukee, WI.
UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company on form UHICI-POL-1 et al., in Texas on UHICI-POL-1 and in Virginia on UHICI-POL-1-VA. Critical Illness coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.
UnitedHealthcare Accident Protection product is provided by UnitedHealthcare Insurance Company on form UHCAC-POL-1 (01/12) et al., in Texas on form UHCAC-POL-1-TX (01/12) and in Virginia on UHCAC-POL-1-VA (01/12). The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.
UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company on policy forms UHIHIP-POL-TX, et al. and UHIHIP-CERT-TX, et al. in Texas and UHIHIP-POL-VA, et al. and UHIHIP-CERT-VA, et al. in Virginia. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. This product is not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.
Life and Disability products are provided by Unimerica Life Insurance Company of New York. Life and Disability products are provided on policy forms LASD-POL-LIFE NY (05/03) and LASD-POL-ADD/DIS NY (05/03). This policy includes exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.
Specified Disease insurance is provided by Unimerica Life Insurance Company of New York on form UHICI-POL-1-NY. Specified Disease coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.
Accident Protection product is provided by Unimerica Life Insurance Company of New York on form UHCAC-POL-1-NY (01/12). This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.
Hospital Indemnity Protection Plan is provided by Unimerica Life Insurance Company of New York on policy form UHIHIP-POL-NY. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.