UnitedHealthcare Community Plan
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Provider Forms 

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.

Provider Forms 

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.


Pharmacy Prior Authorization & Forms

Refer to the KDHE Pharmacy website for prior authorization criteria and forms.

View the Pharmacy Prior Authorization Criteria

View the Kansas Medicaid Universal Pharmacy/Medical Prior Authorization Request Form

Provider Demographic Change Form

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