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.

EPSDT / Healthchek

Use these forms for appointments related to Early Periodic Screening, Diagnosis, and Treatment (EPSDT) / Healthchek.

Other Forms

Case Rate Agreement Letter  (PDF 38.52 KB)
Obstetrical Needs Assessment  (PDF 271.79 KB)
Coordination of Care  (PDF 110.78 KB)
Botulinum Toxins Prior Authorization Form (PDF 508.57 KB)

Prior Authorization Forms

Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 230.94 KB)
Prior Authorization Fax Request (PDF 50.26 KB)

Quick Reference Guides

Ohio Par Quick Reference Guide  (PDF 495.83 KB)
Ohio Non-Par Quick Reference Guide (PDF 509.55 KB)

Medical Injectables

To review the clinical criteria/guidelines used to conduct medical necessity reviews, please use this link:https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____


Frequently Requested Forms

HP Acthar Gel Prior Authorization Form (PDF 225.84 KB)

Hysterectomy (PDF 19.72 KB)

Immune Globulin Prior Authorization Form (PDF 231.45 KB)

Sterilization Form (PDF 126.4 KB)

Sterilization Form (Español) (PDF 373.11 KB)

Sleep Study Worksheet (PDF 192.95 KB)