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.

Member Applicable Resources

PCP Letter to Adolescents for Checkup Reminder (PDF 8.11 KB)

PCP Letter to Adolescents for Checkup Reminder (Español) (PDF 8.56 KB)

General Provider Forms

Reporting Critical Incidents Including Abuse, Neglect and Exploitation (PDF 512.22 KB) - 10.6.2016

STAR Kids Letter of Intent (PDF 17.1 KB) - 7.28.2016

LTSS Services Offered Pre-credentialing Form (PDF 60.2 KB) - 7.28.2016

LTSS Credentialing Application (PDF 128.41 KB) - 7.28.2016 

Employment Assistance Monthly Progress Report (PDF 291.04 KB) - 8.12.2015

Employment Services Initial Assessment (PDF 117.37 KB) - 8.12.2015

Supported Employment Monthly Progress Report (PDF 116.37 KB) - 8.12.2015

Attendant Compensation Rate Enhancement Request (PDF 48.81 KB) - Posted 9.29.2015

Claim Reconsideration Form (PDF 55.64 KB)

JOIN for ME Physician Referral Form (PDF 136.06 KB)

Do Not Resuscitate Order (PDF 27.46 KB)

Request for Taxpayer Identification Number and Certification Form (PDF 256.43 KB)

Disclosure and Consent Form (Authorization for Release and Use of Confidential Information) (PDF 99.65 KB)

Disclosure and Consent Form (Authorization for Release and Use of Confidential Information) Español (PDF 110 KB)

Disclosure and Consent Form (Authorization for Release and Use of Health Information) (PDF 98.04 KB)

Disclosure and Consent Form (Authorization for Release and Use of Health Information) Español (PDF 35.24 KB)

Obstetrical Health Risk Assessment Form (PDF 80.21 KB)

Provider Acknowledgment of Receipt of Manaul (PDF 19.51 KB)

Provider Address and Tax Updates - Updated May 12, 2015

Sleep Study Worksheet (PDF 192.95 KB)

DNR (PDF 24.69 KB)

Power of Attorney (PDF 62.83 KB)

Living Will (PDF 65.26 KB)

Appeal Request Form: Editable (PDF 47.96 KB)

Provider Complaint / Grievance Form (PDF 37.22 KB)

Prior Authorization Forms

Where to send Prior Authorization Requests (PDF 42.01 KB) - 3.9.2016

Standard Prior Authorization form: Texas Department of Insurance (PDF 572.54 KB)  - 7.9.2015

Texas Standard PA Request Instructions 2015 (PDF 363.65 KB)

Standard Pharmacy Prior Authorization Form: Texas Department of Insurance (PDF 1.04 MB) - 7.9.2015

Botulinum Toxins Prior Authorization Form (PDF 508.56 KB)

HP Acthar Gel Prior Authorization Form (PDF 225.97 KB)

Immune Globulin Prior Authorization Form (PDF 233.05 KB)

Makena Prior Authorization Form (PDF 229.31 KB)

Xolair Prior Authorization Form (PDF 506.36 KB)