Please select the state where you practice.

Provider Forms 

 

KS Disclosure of Ownership Control Interest

 

Prior Authorization Form

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

Primary Care Physician (PCP) Change Request Form (PDF 231.42 KB)

Primary Care Physician (PCP) Lock-In Referral Form (PDF 65.39 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.