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Member forms

• Frequently asked questions

Find commonly used forms and documents

View the links below to find member forms you can download, making it quicker to take action on claims, reimbursements and more. 

If you can’t find the form or document you’re looking for below, sign in to your member site to find more.

Sign in to see forms for your health plan

• Plan through your employer
• Medicare plan
• Medicaid plan
• Sign in to another secure site

Download forms here

Reimbursement and claim forms, medical reimbursement and claim forms.

To request COVID-19 reimbursement, please select one of the COVID-19 Testing/Vaccine Administration reimbursement types. This form can also be used for foreign care, DME, physical therapy and other qualified services or purchases. 

Note: This form is for individuals that currently have, or previously had, a UnitedHealthcare insurance plan and sign in using myuhc.com. This form cannot be used by UnitedHealthcare Community Plan members, Medicare & Retirement members, UnitedHealthcare West, Expat, or some other members with insurance through their employer or an individual plan.

• Direct member reimbursement form (pdf)
• Oxford NJ, CT, and ASO (any state) medical claim form (pdf)
• Oxford NY medical claim form (pdf)
• PA medical claim form - digital format (pdf)

Dental claim form

• Dental claim form (online)

Flexible Spending Account (FSA) forms

• Flexible Spending Account (FSA) request for health care reimbursement (pdf)
• Flexible Spending Account (FSA) request for dependent care reimbursement (pdf)

Health Reimbursement Account (HRA) forms

• Health Reimbursement Account (HRA) claim form (pdf)

Health Savings Account (HSA) forms

• Health Savings Account (HSA) forms (online list)

Sweat Equity® Reimbursement forms

• Sweat Equity® Reimbursement Form for New York UnitedHealthcare small group (1-100) and large group (101+) members – English (pdf)
• Sweat Equity® Reimbursement Form for New York for UnitedHealthcare small group (1-100) and large group (101+) members – Spanish (pdf)
• Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members – English (pdf)
• Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members – Spanish (pdf)

*Oxford members, please look to the Oxford health plan forms (drawer below) to obtain your Sweat Equity Reimbursement Form.

Tax, legal and appeals forms

Irs forms 1095-a, 1095-b and 1095-c.

There are 3 types of health insurance information forms you may need to file your taxes.

Form 1095-A is the Health Insurance Marketplace Statement. You'll receive this form if you enrolled in coverage through the  Marketplace.

Form 1095-B  is a form you may need when you file your taxes, depending on the law in your state.

Most fully insured UnitedHealthcare members will not automatically receive a paper copy of Form 1095-B due to a change in the tax law . However, Form 1095-B will continue to be available on member websites or by request.

Here are the ways to get a copy of your Form 1095-B:

• Sign in to your health plan account  to view and/or download and print a copy of the form
• Call the number on your member ID card or other member materials 
• Complete the  1095B Paper Request Form  and email it to your health plan at the email address listed on the form

Call UnitedHealthcare using the number on your member ID card or other member materials if you have questions about this form.

Form 1095-C is a form you may receive from your employer if get your health plan through work. 

Learn more about these health care information forms for individuals from the Internal Revenue Service.

Appeals and Grievance Medical and Prescription Drug Request form

Note : Complete and submit this form for appeals or grievances for medical or pharmacy services you received. This excludes Community Plan members, Medicare & Retirement members, UHC West, Surest and some members with insurance through their employer or an individual plan. Before you start, make sure you have all applicable documents from your provider. Providing supporting documents will help with the appeal review.

California grievance forms for United Healthcare Benefit Plans of California

• English (pdf)
• Español (pdf)

Minnesota appeals and grievance forms

• MN Managed Health Care Plans UnitedHealthcare of Illinois
• MN Insurance Plans United Healthcare Insurance Company

Certificate of Coverage (COC) or Proof of Lost Coverage (POLC) form

Use this form to request Certificate of Coverage (COC) 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, Empire or some members with insurance through their employer or an individual plan.

Dental grievance, enrollment and exception forms

Dental enrollment and exception forms.

• SignatureValue dental V160 brochure and enrollment form (pdf)
• Non-participating dentist nomination form (online)
• Clinical exception form
• New York State Personal Protective Equipment Charge Restriction Assistance (pdf)

Dental grievance and appeals

• 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)

Power of attorney and release of information forms

Use this form to authorize the release of your health information or to appoint someone to act as your representative with UnitedHealthcare. This form should not be used by Oxford members.

Use this form to authorize the release of your health information or to appoint someone to act as your representative with UnitedHealthcare.

Plan and state specific forms for Continuity of Care, Transition of Care, reimbursement, member change requests and more

National continuity of care and medication transition of care forms.

For members with plans through work. Ask your employer to confirm which form may apply to your specific plan. 

• FulIy Insured Transition of Care, Continuity of Care form
• ASO Transition of Care, Continuity of Care form (English)
• ASO Transition of Care, Continuity of Care form (Spanish)
• Level Funded Transition of Care, Continuity of Care form

For members that need help or more time to transfer medications, the Pharmacy Transition of Care flier (TOC) can help guide you.

• Pharmacy Transition of Care (English)
• Pharmacy Transition of Care (Spanish)

State specific Continuity of Care forms

Members: use the following forms if you have a fully-insured plan in one of the states listed below.

If your state is not listed: choose a national Continuity of Care form in the section above or ask your employer to help you find the correct form for your plan.

Choice, Choice Plus, Non-Differential ("Non-Diff" or "Options PPO"), Select and Select Plus, Core; SignatureValue HMO, Core Essentials Network, and Navigate Continuity of Care.

English | Spanish |  中文

North Carolina

Fully Insured Transition of Care, Continuity of Care form

South Carolina

Oxford health plan forms

Claim forms

• Oxford NJ, CT, and ASO (any state) – Medical claim form
• Oxford NY – Medical claim form

Continuity of Care forms

• Oxford CT — UHC Transition of Care, Continuity of Care form
• Oxford NJ — UHC Transition of Care, Continuity of Care form
• Oxford NY — UHC Transition of Care, Continuity of Care form
• Oxford Level Funded Continuity of Care Form

Prescription mail order and reimbursement forms

• Oxford prescription mail-order form
• Oxford prescription reimbursement claim form - English
• Oxford prescription reimbursement claim form - Spanish

Provider online search instructions

• How to search online for Oxford providers

Reimbursement forms

• Sweat Equity® Reimbursement Form for New York Oxford small group (1-100) and large group (101+) members – English
• Sweat Equity® Reimbursement Form for New York Oxford small group (1-100) and large group (101+) members – Spanish
• Sweat Equity® Reimbursement Form for Connecticut Oxford small group (1-50) and large group (51+), and New Jersey Oxford large group (51+) members – English
• Sweat Equity® Reimbursement Form for Connecticut Oxford small group (1-50) and large group (51+), and New Jersey Oxford large group (51+) members – Spanish

Looking for employer or broker forms?

• Visit employer resources
• Visit broker and consultant resources

• New User & User Access

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

Select plan type, claims and payments.

• Claims Overpayment Refund Form
• Corrected Claim and Claim Reconsideration Request Form

Exception Requests

• Colorado Standard Exemption Form for Contraceptive Products
• New York Contraceptive Exception Request Form
• Confidential Exchange of Information Form
• Commercial Designation of Authorized Representative Form
• Option Care Health Medication Prescriber Order Form 
• Skilled Nursing Facilities Clinical and Therapy Request Form

Our network

• Demographic Change Form

Prior authorization

Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations online.

• Arizona Health Care Services Prior Authorization Form
• Arizona Prior Authorization Medications DME Medical Devices Form
• Arkansas, Iowa, Illinois, Mississippi, Oklahoma, Virginia, West Virginia Prescription Prior Authorization Form
• California Prescription Prior Authorization Form
• Colorado Prescription Prior Authorization Form
• Fertility Solutions Prior Authorization Request Form
• Illinois Prescription Drugs Prior Authorization Request Form
• Indiana Prescription Prior Authorization Form
• Louisiana Prescription Prior Authorization Form
• Managed Infertility Program Prior Authorization Form
• Massachusetts Cardiac Imaging Prior Authorization Request Form
• Massachusetts Chemotherapy Supportive Care Prior Authorization Request Form
• Massachusetts Hepatitis Medication Prior Authorization Request Form
• Massachusetts Non-OB Ultrasound Request Form
• Massachusetts PET CT Request Form
• Massachusetts Prescription Prior Authorization Form
• Massachusetts Synagis® Prior Authorization Request Form
• Michigan Prescription Drug Prior Authorization Form FIS 2288
• Network Prior Authorization Gap Exception Request Form
• Nevada Cancer Stage 3 or 4 Step Therapy Protocol Prior Authorization Exception Form
• Nevada Medical Standard Prior Authorization Form
• New Hampshire Prescription Prior Authorization Form
• New Mexico Prior Authorization Form
• New York Prior Authorization Predetermination Form
• Oregon Commercial Plan Prescription Prior Authorization Form
• Texas Commercial Prior Authorization Form
• Texas Surest Prescription Prior Authorization Form
• Medicare Direct PFFS Uncollectible Bad Debt Submittal Form

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.

State-specific pharmacy prior authorization forms

• Community Plan Pharmacy Prior Authorization for Prescribers

State-specific forms - General

• District of Columbia
• Massachusetts
• Mississippi
• North Carolina
• Rhode Island

Pharmacy prior authorization

• Alabama Prior Authorization Form for Prescription Benefits
• 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
• Louisiana Prior Authorization Form for Prescription Benefits
• Maryland Prior Authorization Form for Prescription Benefits
• Massachusetts Prior Authorization Form for Prescription Benefits
• Michigan Prior Authorization Form for Prescription Benefits
• Mississippi Prior Authorization Form for Prescription Benefits
• Missouri Prior Authorization Form for Prescription Benefits
• Nevada Prior Authorization Form for Prescription Benefits
• New York Prior Authorization Form for Prescription Benefits
• North Carolina Prior Authorization Form for Prescription Benefits
• Ohio Prior Authorization Form for Prescription Benefits
• Oklahoma Prior Authorization Form for Prescription Benefits
• Tennessee Prior Authorization Form for Prescription Benefits
• Texas Prior Authorization Form for Prescription Benefits
• Virginia Prior Authorization Form for Prescription Benefits
• Washington Prior Authorization Form for Prescription Benefits
• Medicare Advantage
• Community Plan (Medicaid)
• Individual Exchange