UnitedHealthcare Community Plan
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Provider Forms

You'll find all forms we currently use in the following list. Check back frequently for the most current and up-to-date forms.

 

Frequently Requested Forms
 

HP Acthar Gel Prior Authorization Form (PDF 225.84 KB)

Hysterectomy

Immune Globulin Prior Authorization Form (PDF 231.45 KB)

Sterilization Form (PDF 126.4 KB)

Sterilization Form (Español)

Sleep Study Worksheet (PDF 192.95 KB)

 

Early Periodic Screening, Diagnosis, and Treatment (EPSDT) / Healthchek

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

Newborn (PDF 109.72 KB)

4 weeks (PDF 89.37 KB)

2 months (PDF 108.01 KB)

4 months (PDF 89.97 KB)

6 months (PDF 109.84 KB)

9 months (PDF 107.58 KB)

12 months (PDF 106.89 KB)

15 months (PDF 107.71 KB)

18 months (PDF 108.65 KB)

24 months (PDF 94.92 KB)

30 months (PDF 107.53 KB)

3 years (PDF 180.26 KB)

4 years (PDF 108.01 KB)

5 years (PDF 106.46 KB)

6-10 years (PDF 89.58 KB)

11-14 years (PDF 95.75 KB)

15-20 years (PDF 53.36 KB)