Member forms
Find commonly used forms and documents
View the links below to find member forms you can download, making it quicker to take action on claims, reimbursements and more.
If you can’t find the form or document you’re looking for below, sign in to your member site to find more.
Download forms here
Reimbursement and claim forms
-
Direct medical reimbursement form - digital form
To request COVID-19 reimbursement, please select one of the COVID-19 Testing/Vaccine Administration reimbursement types. This form can also be used for foreign care, DME, physical therapy and other qualified services or purchases.
Note: This form is for individuals that currently have, or previously had, a UnitedHealthcare insurance plan and sign in using myuhc.com. This form cannot be used by UnitedHealthcare Community Plan members, Medicare & Retirement members, UnitedHealthcare West, Expat, Empire or some other members with insurance through their employer or an individual plan.
- Direct member reimbursement form (pdf)
- Oxford NJ, CT, and ASO (any state) medical claim form (pdf)
- Oxford NY medical claim form (pdf)
- PA medical claim form - digital format (pdf)
- Sweat Equity® Reimbursement Form for New York UnitedHealthcare small group (1-100) and large group (101+) members – English (pdf)
- Sweat Equity® Reimbursement Form for New York for UnitedHealthcare small group (1-100) and large group (101+) members – Spanish (pdf)
- Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members – English (pdf)
- Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members – Spanish (pdf)
*Oxford members, please look to the Oxford health plan forms (drawer below) to obtain your Sweat Equity Reimbursement Form.
Tax, legal and appeals forms
There are 3 types of health insurance information forms you may need to file your taxes.
Form 1095-A is the Health Insurance Marketplace Statement. You'll receive this form if you enrolled in coverage through the Marketplace.
Form 1095-B is a form you may need when you file your taxes, depending on the law in your state.
Most fully insured UnitedHealthcare members will not automatically receive a paper copy of Form 1095-B due to a change in the tax law. However, Form 1095-B will continue to be available on member websites or by request.
Here are the ways to get a copy of your Form 1095-B:
- Sign in to your health plan account to view and/or download and print a copy of the form
- Call the number on your member ID card or other member materials
- Complete the 1095B Paper Request Form and email it to your health plan at the email address listed on the form
Call UnitedHealthcare using the number on your member ID card or other member materials if you have questions about this form.
Form 1095-C is a form you may receive from your employer if get your health plan through work.
Learn more about these health care information forms for individuals from the Internal Revenue Service.
Note: Complete and submit this form for appeals or grievances for medical or pharmacy services you received. This excludes Community Plan members, Medicare & Retirement members, UHC West, Surest and some members with insurance through their employer or an individual plan. Before you start, make sure you have all applicable documents from your provider. Providing supporting documents will help with the appeal review.
California grievance forms for United Healthcare Benefit Plans of California
-
Certificate of Coverage or Proof of Lost Coverage Form
Use this form to request Certificate of Coverage (COC) document(s) when coverage is still active or to request Proof of Lost Coverage (POLC) document(s) when coverage is no longer active.
This form is for individuals that currently have or previously had insurance through their employer or an individual plan through UnitedHealthcare and sign in using myuhc.com.
This form should not be used by UnitedHealthcare West, Oxford, Expat, Empire or some members with insurance through their employer or an individual plan.
Dental enrollment and exception forms
Dental grievance and appeals
- Dental grievance form (English & Español combined) (pdf)
- CA DENTAL GRIEVANCE FORM (English & Español combined) (pdf)
- CA GRIEVANCE FORM FOR CANCELLATIONS, RECISSIONS AND NONRENEWALS OF AN ENROLLMENT OR SUBSCRIPTION (pdf)
- Kentucky complaint, grievance and appeals (pdf)
- Massachusetts external grievance review form English (pdf)
- Massachusetts external grievance review form Español (pdf)
-
POA/ROI form for individuals with insurance through their employer and UnitedHealth Group employees
Use this form to authorize the release of your health information or to appoint someone to act as your representative with UnitedHealthcare. This form should not be used by Oxford members.
-
POA/ROI form for individuals on a community plan
Use this form to authorize the release of your health information or to appoint someone to act as your representative with UnitedHealthcare.
Plan and state specific forms for Continuity of Care, Transition of Care, reimbursement, member change requests and more
For members with plans through work. Ask your employer to confirm which form may apply to your specific plan.
- FulIy Insured Transition of Care, Continuity of Care form
- ASO Transition of Care, Continuity of Care form (English)
- ASO Transition of Care, Continuity of Care form (Spanish)
- Level Funded Transition of Care, Continuity of Care form
For members that need help or more time to transfer medications, the Pharmacy Transition of Care flier (TOC) can help guide you.
Members: use the following forms if you have a fully-insured plan in one of the states listed below.
If your state is not listed: choose a national Continuity of Care form in the section above or ask your employer to help you find the correct form for your plan.
North Carolina
South Carolina
Claim forms
Member enrollment/change request forms
- Oxford NJ – Large Employer Member Enrollment/Change Request Form OHI/OHP
- Oxford NJ – Small Employer Member Enrollment/Change Request Form OHI/OHP
- Oxford NY – Large and Small Employer Member Enrollment/Change Request Form OHI
- Oxford CT – Large and Small Employer Member Enrollment/Change Request Form OHI/OHP
Continuity of Care forms
- Oxford CT — UHC Transition of Care, Continuity of Care form
- Oxford NJ — UHC Transition of Care, Continuity of Care form
- Oxford NY — UHC Transition of Care, Continuity of Care form
- Oxford Level Funded Continuity of Care Form
Prescription mail order and reimbursement forms
- Oxford prescription mail-order form
- Oxford prescription reimbursement claim form - English
- Oxford prescription reimbursement claim form - Spanish
Provider online search instructions
Reimbursement forms
- Sweat Equity® Reimbursement Form for New York Oxford small group (1-100) and large group (101+) members – English
- Sweat Equity® Reimbursement Form for New York Oxford small group (1-100) and large group (101+) members – Spanish
- Sweat Equity® Reimbursement Form for Connecticut Oxford small group (1-50) and large group (51+), and New Jersey Oxford large group (51+) members – English
- Sweat Equity® Reimbursement Form for Connecticut Oxford small group (1-50) and large group (51+), and New Jersey Oxford large group (51+) members – Spanish
SignatureValue managed care CA — Continuity of Care forms
SignatureValue managed care CA — grievance forms
SignatureValue managed care OK, OR, TX and WA — Continuity of Care forms
