UnitedHealthcare Community Plan
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Please select the state where you practice.

You'll find all forms we currently use in the following list.

We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.

National Disclosure Provider Roster Addendum Form (PDF 42.73 KB)

KS Disclosure of Ownership Control Interest

Provider Disclosure of Ownership and Control Interest Statement - FAQ (PDF 256.6 KB)

 

Prior Authorization Form
Providers can use the Prior Authorization Form (PDF 228.04 KB) to fax in a prior authorization request.

PCP Change Request Form (PDF 231.42 KB)

Providers can click here (PDF 27.47 KB) for information regarding the process to follow to submit unsolicited refunds to UnitedHealthcare Community & State for the KanCare program. Click here (XLS 24 KB) for the spreadsheet providers can use to document information regarding the refund.

Provider Demographic Change Form
Providers can click here (PDF 401.58 KB) to access the form to submit to make changes to their demographics like address, phone number, change in practice name, adding a physician, etc. Form includes instructions on where to submit completed form.