Find commonly used forms

Here are some commonly used forms you can download to make it quicker to take action on claims, reimbursements and more. If you can’t find the form you’re looking for below, log in on myuhc.comOpens a new window® to find more.

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California Continuity of Care Forms for SignatureValue Managed Care Members

California Grievance Forms for SignatureValue Managed Care Members

Oklahoma, Oregon, Texas and Washington Continuity of Care Form for SignatureValue Managed Care Members

Choice, Choice Plus, Non-Differential ("Non-Diff" or "Options PPO"), Select and Select Plus, Core; Core Essentials Network, and Navigate Continuity of Care

How to file a claim

1. Choose the appropriate claim packet below.

2. Complete, sign and date the necessary forms in the packet.

3. Use the contact information on the form to fax or email your claim.
— E-mail: fpcustomersupport@uhc.comOpens a new window
— Fax: 1-888-505-8550
— Phone: If you have any questions, please call our claims department at 1-888-299-2070, between 8 a.m. and 6 p.m. ET.

Claim Form Packets

(Note: Not for members living in New York or California.)

Disability Insurance

Life Insurance

Hospital Indemnity Protection Plan

Critical Illness Protection Plan

Note: Use if your plan includes Child Critical Illness, Additional Critical Illness, or Partial Benefit Critical Illness benefit options. If you are not sure if your plan includes these benefits, please refer to your Certificate of Coverage or contact your employer.

Accident Protection Plan

Standalone Authorization

This optional form is used by the member to provide UnitedHealthcare with authorization to discuss their claim with someone other than the member.

Note about email: We cannot guarantee the security of any communication transmitted through the internet. We are not liable for the illegal acts of third parties such as criminal hackers. Please use your best judgment when deciding how to email your information. We can accept emails sent with or without encryption.

UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products in California by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX(05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL(05/03) and UHCLD-POL 2/2008.  The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.  For costs and complete details of the coverage, call or write your insurance agent or the company.  Some products are not available in all states.  UnitedHealthcare Insurance Company is located in Hartford, CT and Unimerica Life Insurance Company is located in Milwaukee, WI.

UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company on form UHICI-POL-1 et al., in Texas on UHICI-POL-1 and in Virginia on UHICI-POL-1-VA.  Critical Illness coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor.  The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.  For costs and complete details of the coverage, call or write your insurance agent or the company.  Some products are not available in all states.  UnitedHealthcare Insurance Company is located in Hartford, CT.

UnitedHealthcare Accident Protection product is provided by UnitedHealthcare Insurance Company on form UHCAC-POL-1 (01/12) et al., in Texas on form UHCAC-POL-1-TX (01/12) and in Virginia on UHCAC-POL-1-VA (01/12).  The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.  For costs and complete details of the coverage, call or write your insurance agent or the company.  Some products are not available in all states.  UnitedHealthcare Insurance Company is located in Hartford, CT.

UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company on policy forms UHIHIP-POL-TX, et al. and UHIHIP-CERT-TX, et al. in Texas and UHIHIP-POL-VA, et al. and UHIHIP-CERT-VA, et al. in Virginia. The product provides a limited benefit for certain hospital indemnity plan benefits.  Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor.  The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.  For costs and complete details of the coverage, call or write your insurance agent or the company.  This product is not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.

Life and Disability products are provided by Unimerica Life Insurance Company of New York. Life and Disability products are provided on policy forms LASD-POL-LIFE NY (05/03) and LASD-POL-ADD/DIS NY (05/03). This policy includes exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.

Specified Disease insurance is provided by Unimerica Life Insurance Company of New York on form UHICI-POL-1-NY. Specified Disease coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.

Accident Protection product is provided by Unimerica Life Insurance Company of New York on form UHCAC-POL-1-NY (01/12). This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY.

Hospital Indemnity Protection Plan is provided by Unimerica Life Insurance Company of New York on policy form UHIHIP-POL-NY. The product provides a limited benefit for certain hospital indemnity plan benefits.  Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor.  The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.  For costs and complete details of the coverage, call or write your insurance agent or the company.  Unimerica Life Insurance Company of New York is located in New York, NY.

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