Please select the state where you practice.

Provider Forms 


National Disclosure Provider Roster Addendum Form (PDF 42.73 KB)

KS Disclosure of Ownership Control Interest

Provider Disclosure of Ownership and Control Interest Statement - FAQ (PDF 256.6 KB)


Prior Authorization Form

Providers can use the Prior Authorization Form (PDF 228.04 KB) to fax in a prior authorization request.

PCP Change Request Form (PDF 231.42 KB)


Provider Demographic Change Form

Use the Provider Demographic Change Form (PDF 401.58 KB) to submit or to make changes to your demographics like address, phone number, change in practice name, adding a physician, etc. The form also includes instructions on how to submit the form when it's completed.


Unsolicited Refund Process

Learn more (PDF 27.47 KB) about the process on how to submit unsolicited refunds to UnitedHealthcare Community & State for the KanCare program.

View the spreadsheet (XLS 24 KB) to use for documenting information regarding the refund.