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 in portal | PDF
Exception Requests
- Colorado Standard Exemption Form for Contraceptive Products Complete in portal | PDF
- New York Contraceptive Exception Request Form Complete in portal | PDF
Other
- Colorado Serious Mental Illness Step Therapy Exception Form PDF
- Confidential Exchange of Information Form PDF
- Commercial Designation of Authorized Representative Form Complete in portal | PDF
- Option Care Health Medication Prescriber Order Form PDF
- Skilled Nursing Facilities Clinical and Therapy Request Form PDF
Our network
- Demographic Change Form Complete in portal
Prior authorization
Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations online.
- Arizona Health Care Services Prior Authorization Form Complete in portal | PDF
- Arizona Prior Authorization Medications DME Medical Devices Form Complete in portal | PDF
- Colorado Prescription Prior Authorization Form Complete in portal | PDF
- Illinois Prescription Drugs Prior Authorization Request Form Complete in portal | PDF
- Indiana Prescription Prior Authorization Form Complete in portal | PDF
- Louisiana Prescription Prior Authorization Form Complete in portal | PDF
- Massachusetts Cardiac Imaging Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Chemotherapy Supportive Care Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Hepatitis Medication Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Non-OB Ultrasound Request Form Complete in portal | PDF
- Massachusetts PET CT Request Form Complete in portal | PDF |
- Massachusetts Prescription Prior Authorization Form PDF
- Massachusetts Synagis® Prior Authorization Request Form Complete in portal | PDF
- Michigan Prescription Drug Prior Authorization Form FIS 2288 PDF
- Network Prior Authorization Gap Exception Request Form Complete in portal | PDF |
- Nevada Cancer Stage 3 or 4 Step Therapy Protocol Prior Authorization Exception Form Complete in portal | PDF
- Nevada Medical Standard Prior Authorization Form Complete in portal | PDF
- New Hampshire Prescription Prior Authorization Form PDF
- New Mexico Prior Authorization Form Complete in portal | PDF
- New York Prior Authorization Predetermination Form PDF
- Oregon Commercial Plan Prescription Prior Authorization Form Complete in portal | PDF |
- Texas Commercial Prior Authorization Form PDF
- Texas Surest Prescription Prior Authorization Form Complete in portal | PDF
- West Virginia Pre-Determination Form Complete in portal
- Appointment of Representative Form
- Corrected Claim and Claim Reconsideration Request Form
- Medicare Direct PFFS Uncollectible Bad Debt Submittal Form
- Skilled Nursing Facilities Clinical and Therapy Request 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.
Claims and payments
Other
State-specific pharmacy prior authorization forms
State-specific forms - General
- Arizona
- California
- Colorado
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Indiana
- Iowa
- 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
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
General
- 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 in portal | PDF
Exception Requests
- Colorado Standard Exemption Form for Contraceptive Products Complete in portal | PDF
- New York Contraceptive Exception Request Form Complete in portal | PDF
Other
- Colorado Serious Mental Illness Step Therapy Exception Form PDF
- Confidential Exchange of Information Form PDF
- Commercial Designation of Authorized Representative Form Complete in portal | PDF
- Option Care Health Medication Prescriber Order Form PDF
- Skilled Nursing Facilities Clinical and Therapy Request Form PDF
Our network
- Demographic Change Form Complete in portal
Prior authorization
Sign in to the UnitedHealthcare Provider Portal to complete prior authorizations online.
- Arizona Health Care Services Prior Authorization Form Complete in portal | PDF
- Arizona Prior Authorization Medications DME Medical Devices Form Complete in portal | PDF
- Colorado Prescription Prior Authorization Form Complete in portal | PDF
- Illinois Prescription Drugs Prior Authorization Request Form Complete in portal | PDF
- Indiana Prescription Prior Authorization Form Complete in portal | PDF
- Louisiana Prescription Prior Authorization Form Complete in portal | PDF
- Massachusetts Cardiac Imaging Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Chemotherapy Supportive Care Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Hepatitis Medication Prior Authorization Request Form Complete in portal | PDF
- Massachusetts Non-OB Ultrasound Request Form Complete in portal | PDF
- Massachusetts PET CT Request Form Complete in portal | PDF |
- Massachusetts Prescription Prior Authorization Form PDF
- Massachusetts Synagis® Prior Authorization Request Form Complete in portal | PDF
- Michigan Prescription Drug Prior Authorization Form FIS 2288 PDF
- Network Prior Authorization Gap Exception Request Form Complete in portal | PDF |
- Nevada Cancer Stage 3 or 4 Step Therapy Protocol Prior Authorization Exception Form Complete in portal | PDF
- Nevada Medical Standard Prior Authorization Form Complete in portal | PDF
- New Hampshire Prescription Prior Authorization Form PDF
- New Mexico Prior Authorization Form Complete in portal | PDF
- New York Prior Authorization Predetermination Form PDF
- Oregon Commercial Plan Prescription Prior Authorization Form Complete in portal | PDF |
- Texas Commercial Prior Authorization Form PDF
- Texas Surest Prescription Prior Authorization Form Complete in portal | PDF
- West Virginia Pre-Determination Form Complete in portal
- Appointment of Representative Form
- Corrected Claim and Claim Reconsideration Request Form
- Medicare Direct PFFS Uncollectible Bad Debt Submittal Form
- Skilled Nursing Facilities Clinical and Therapy Request 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.
Claims and payments
Other
State-specific pharmacy prior authorization forms
State-specific forms - General
- Arizona
- California
- Colorado
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Indiana
- Iowa
- 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
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