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Provider Forms 

You'll find all forms we currently use in the following list. Check back frequently to see what forms have been updated or changed.


UnitedHealthcare Community Plan

Abortion Necessity Certification Form (PDF 71.34 KB)

Adult Health Assessment Form (PDF 600.36 KB) - 3.29.2017

Adult Health Assessment Form (Spanish) (PDF 551.81 KB) - 8.11.2016

Case Activity Report (PDF 64.06 KB) - 2.22.2016

Child / Pediatric Health Assessment Form (PDF 568.81 KB) - 8.11.2016

Child / Pediatric Health Assessment Form (Spanish) (PDF 539.09 KB) - 8.11.2016

Claim Dispute Form (PDF 191.93 KB) – 2.22.2016

Claim Reconsideration Form (PDF 198.87 KB) – 2.22.2016

Claim for Targeted Medical Care Form (PDF 57.74 KB) - 1.2.2018

Consent for Sterilization Form (PDF 33.75 KB)

Consumer-Directed Attendant Care (CDAC) Daily Service Record (PDF 85.85 KB) - 5.15.2017

Critical Incident Reporting Form (PDF 987.64 KB) (click here for help completing this form) - 12.19.2016 

Election of Hospice Benefit (PDF 14.79 KB) - 2.23.2016

Entity / Group Provider Disclosure of Ownership and Control of Interest Form (PDF 594.98 KB)

Health Homes Member Enrollment, Disenrollment Form (PDF 183.2 KB) - 10.3.2016

Home and Vehicle Modification Approval Form (PDF 60.95 KB) - 10.31.2017 

Home Modification Property Owner Notice Form (PDF 61.01 KB) - 10.31.2017

Individual Provider Disclosure of Ownership and Control of Interest Form (PDF 308 KB)

PCP Change Form: hawk-i (PDF 65.23 KB) - 4.15.2016

PCP Change Form: IA Health Link (PDF 60.92 KB) - 4.15.2016

PCP Discharge Form: hawk-i (PDF 124.86 KB) - 8.8.2016 

PCP Discharge Form: IA Health Link (PDF 495.86 KB) - 8.8.2016

Person-Centered Treatment Plan Form (PDF 2.45 MB) – 7.20.18

Prenatal Risk Assessment Form (PDF 138.92 KB) - 4.4.2018

Prior Authorization Request Form - Acute Medical  (PDF 136.23 KB) – 3.26.2018

Revocation of Medicaid Hospice Benefit (PDF 10.33 KB) - 2.23.2016


Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.

If you don’t want to buy and bill a specialty pharmacy medication covered under the member’s medical benefit, you may order it through the following network specialty pharmacy:

Network Specialty Pharmacy

Phone Number



The following specialty pharmacies also provide certain types of specialty medications:

Network Specialty Pharmacy

Medication Category

Phone Number

Accredo (nursing services)

Enzyme Deficiency

Gaucher's Disease

Immune Globulin

Pulmonary Hypertension



Option Care (nursing services)

Enzyme Deficiency

Gaucher's Disease


Immune Globulin



CVS Caremark Specialty Pharmacy

Pulmonary Hypertension


Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.

Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.

Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.


Utilization Guidelines

Utilization Guidelines, such as Milliman Utilization Care Guidelines, may be used as part of the prior authorization process. You may request a copy of a specific guideline by calling 1-888-650-3462.

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