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  PDFopen_in_new 
• Corrected Claim and Claim Reconsideration Request Form  Complete onlineopen_in_new | PDFopen_in_new

Exception Requests

• Colorado Standard Exemption Form for Contraceptive Products  Complete onlineopen_in_new | PDFopen_in_new
• New York Contraceptive Exception Request Form  Complete onlineopen_in_new | PDFopen_in_new

Other

• Colorado Serious Mental Illness Step Therapy Exception Form PDFopen_in_new
• Confidential Exchange of Information Form  PDFopen_in_new
• Commercial Designation of Authorized Representative Form  Complete onlineopen_in_new | PDFopen_in_new
• Option Care Health Medication Prescriber Order Form  PDFopen_in_new 
  
• Skilled Nursing Facilities Clinical and Therapy Request Form  PDFopen_in_new
  

Our network

• Demographic Change Form  Complete onlineopen_in_new
• Provider Termination Appeal Form PDFopen_in_new

Prior authorization

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

• Arizona Health Care Services Prior Authorization Form  Complete onlineopen_in_new |  PDFopen_in_new
• Arizona Prior Authorization Medications DME Medical Devices Form  Complete onlineopen_in_new | PDFopen_in_new
• California Prescription Drugs Prior Authorization form Complete onlineopen_in_new | PDFopen_in_new
• Colorado Prescription Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new
• Empire Plan Predetermination Form PDFopen_in_new
• Illinois Prescription Drugs Prior Authorization Request Form  Complete onlineopen_in_new | PDFopen_in_new
• Indiana Prescription Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new
• Louisiana Prescription Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new
• Massachusetts Cardiac Imaging Prior Authorization Request Form  Complete onlineopen_in_new | PDFopen_in_new
  
• Massachusetts Chemotherapy Supportive Care Prior Authorization Request Form  Complete onlineopen_in_new | PDFopen_in_new
• Massachusetts Hepatitis Medication Prior Authorization Request Form  Complete onlineopen_in_new | PDFopen_in_new
• Massachusetts Non-OB Ultrasound Request Form  Complete onlineopen_in_new | PDFopen_in_new
• Massachusetts PET CT Request Form  Complete onlineopen_in_new | PDFopen_in_new | 
• Massachusetts Prescription Prior Authorization Form  PDFopen_in_new
• Massachusetts Synagis® Prior Authorization Request Form  Complete onlineopen_in_new | PDFopen_in_new 
• Michigan Prescription Drug Prior Authorization Form FIS 2288  PDFopen_in_new
  
• Network Prior Authorization Gap Exception Request Form  Complete onlineopen_in_new | PDFopen_in_new | 
• Nevada Cancer Stage 3 or 4 Step Therapy Protocol Prior Authorization Exception Form  Complete onlineopen_in_new | PDFopen_in_new
  
• Nevada Medical Standard Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new
• New Hampshire Prescription Prior Authorization Form  PDFopen_in_new
  
• New Mexico Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new
• Oregon Commercial Plan Prescription Prior Authorization Form  Complete onlineopen_in_new | PDFopen_in_new | 
• Texas Commercial Prior Authorization Form  PDFopen_in_new
• West Virginia Pre-Determination Form  Complete onlineopen_in_new