UnitedHealthcare Community Plan
You appear to be browsing this site using Internet Explorer 6. This browser is now out of date. For safer, more reliable browsing it is recommended that you upgrade your browser to Firefox, Safari or Internet Explorer 7 or 8.
Shortcut Navigation:
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.

Maternity Care Management Notification Form (PDF 103.79 KB)

Change PCP Request Form (PDF 157 KB)

Gaucher's Disease Enzyme Therapy Prior Authorization Form (PDF 231.68 KB)p

Individual Disclosure of Ownership and Control of Interest Form click here (PDF 267.31 KB) for PDF version.

Group Disclosure of Ownership and Control of Interest Form click here (PDF 218.84 KB) for PDF version.

Radiology Prior Authorization CPT Code List (PDF 252.57 KB)

Prior Authorization Fax Request Form (PDF 113.76 KB)

Botulinum Toxins Prior Authorization Form (PDF 508.59 KB)

HP Acthar Gel Prior Authorization Form (PDF 225.99 KB)

Immune Globulin Prior Authorization Form (PDF 233.05 KB)

Makena Prior Authorization (PDF 229.09 KB)

Xolair Prior Authorization Form (PDF 508.96 KB)

Sleep Study Worksheet (PDF 192.95 KB)

Coverage Form (PDF 10.75 KB)
Coordination of Care Checklist (PDF 429.74 KB)
Universal PIN Form  (PDF 37.29 KB)
Universal PIN Electronic Form  (PDF 35.06 KB)
Provider Compliance Checklist  (PDF 80.53 KB)
Title VI Article  (PDF 41.06 KB)
Prior Authorization Fax Request Form  (PDF 113.76 KB)
Critical Incident Reporting Form  (PDF 53.74 KB)
TennCare Disclosures and Medicaid ID Requirements
Medicaid Identification Numbers
Provider Dispute Form  (PDF 73.16 KB)
Recoup Request Form 2011  (PDF 41.21 KB)
Maternity CM Notification Form  (PDF 21.79 KB)
East and Middle Region Medical Necessity Form  (PDF 10.83 KB)
West Region Medical Necessity Form  (PDF 10.52 KB)
Electronic Visit Verification (EVV) Data Collection Form  (PDF 105.47 KB)
Provider Requirements Standards Assessment and Documentation Review Form  (PDF 49.38 KB)
Panel Status Change Request Form (PDF 82.46 KB)

 

ASH Forms

Abortion Instructions Form (PDF 22.59 KB)
Hysterectomy and Hysterectomy (Español) Instructions Form (PDF 32.06 KB)
Sterilization Consent and Sterilization Consent Instructions Form (PDF 202.89 KB)

TennCare Miscellaneous Provider Forms
CHOICES (Long Term Care)

Prior Authorization Fax Form
Provider Application  (PDF 93.23 KB)
Provider Change Form (PDF 112.29 KB)
UnitedHealthcare Community Plan (TennCare)Prior Authorization Fax Form

Bus Pass Exemption Forms
Bus Exemption Form-Brentwood  (PDF 37.89 KB)
Bus Exemption Form-Chattanooga  (PDF 36.77 KB)
Bus Exemption Form-Kingsport  (PDF 36.77 KB)
Bus Exemption Form-Knoxville  (PDF 36.75 KB)
Bus Exemption Form-Memphis (PDF 36.74 KB)

UnitedHealthcare Dual Complete (Special Needs Product (SNP)
DSNP Outpatient Observation Notification Form (PDF 35.73 KB)