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.


Frequently Requested Forms

National Disclosure Provider Roster Addendum Form (PDF 42.73 KB)

Group Disclosure of Ownership and Control of Interest Form click here (PDF 519.75 KB) for PDF version.

Individual Disclosure of Ownership and Control of Interest Form click here (PDF 427.75 KB) for PDF version.

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

Medical Prior Authorization Form (PDF 113.75 KB)

DME Prior Authorization Request Form (PDF 82.69 KB)

Home Health Care Authorization Form (PDF 82.03 KB)

Infusion Fax Authorization Form (PDF 45.21 KB)

PCP Change Request Form (PDF 114.12 KB)

PCP Change Request Form for Children's Health Care of Port Huron (PDF 151.48 KB)

Claim Reconsideration Request Form (PDF 229.98 KB)

OB/GYN Data Submission Form (PDF 92.57 KB)

Prenatal Notification Form (PDF 93.49 KB)

Botulinum Toxins Prior Authorization Form (PDF 507.92 KB)

HP Acthar Gel Prior Authorization Form (PDF 224.75 KB)

Immune Globulin Prior Authorization Form (PDF 231.39 KB)

Makena Prior Authorization Form (PDF 228.16 KB)


Other Forms

Consent for Sterilization
(PDF 26.48 KB)Asthma Action Plan  (PDF 119.05 KB)
Asthma Exclusion Form (PDF 19.32 KB)
Breast Cancer Screening Exclusion Form (PDF 19.14 KB)
Certificate of Specialty Services (PDF 33.6 KB)
Cervical Cancer Screening Exclusion Form (PDF 19.18 KB)
Claims Inquiry Status Form (PDF 48.24 KB)
Consent Submission Form (PDF 290.2 KB)
Delivery Admission Review Form (PDF 47.24 KB)
Diabetes Checklist - MQIC (PDF 14.51 KB)
Diabetes Exclusion Form (PDF 18.88 KB)
Gold - COPD Therapy Stages (PDF 29.58 KB)
Health Risk Assessment for Healthy Michigan: Letter (PDF 348.18 KB) | Assessment (DOCX 702.18 KB)
2016 Mileage Reimbursement Instructions (PDF 22.52 KB)
2016 Mileage Reimbursement Form (PDF 21.65 KB)
MDCH Maternal Infant Health Program Bulletin & Forms (PDF 1.24 MB)
Meals and Lodging Prior Authorization Form (PDF 97.72 KB)
Maternal Support Services (MSS) Screening Tool (PDF 26.5 KB)
Medical Record Documentation Review (PDF 33.75 KB)
UnitedHealthcare Community Plan Site Review Tool (PDF 78.54 KB)
Waiver of Liability Statement (PDF 79.02 KB)  
Sleep Study Worksheet (PDF 192.95 KB)