These optional forms are used by the member to allow UnitedHealthcare to discuss their application with someone other than the member. Check out the forms below left to find forms that you can download so you can take faster action in case of claims, refunds and more. 3. Use the form details to send your request by fax or email. DocuSign is a user-friendly application that speeds up the contract process by allowing you to verify and sign contracts via email – it replaces the need to print, sign and return contracts. UnitedHealthcare Life and Disability products are supplied by UnitedHealthcare Insurance Company and some products in California by Uneimerica Life Insurance Company. Products for life and disability are provided on the LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., Texas on laSD-POL-TX (05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL (05/03) and UHCLD-POL 2/2008. Policies have exclusions, restrictions, benefit cuts and conditions under which the policy can come into force or cease. For the full costs and details of insurance coverage, call or write to your insurance agent or company. Some products are not available in all states.

UnitedHealthcare Insurance Company is headquartered in Hartford, CT and Unimerica Life Insurance Company located in Milwaukee, WI. Note: Fill out this form and send it for complaints or complaints about the medical or pharmacy services you have received. This excludes the UHC West. Before you start, make sure you have all applicable documents from your supplier. The provision of supporting documentation will assist in the review of the complaint. Please return your signed contract as soon as possible. We then have it on hand, so once you have approved the application for a deposit authorization, we will be able to put your contract in place in our system. It can take up to four weeks for the installation to be completed. This form should not be used by members of UnitedHealthcare West, Oxford, Expat and Empire Plan.

This optional form is used by the member to request that direct deposit be initiated for all examinations of disability, life and supplementary health benefits. If you can`t find the form or document you`re looking for below, log on to your website for more information. If you join a medical group that already has a participation agreement with UnitedHealthcare, you will not receive a direct contract. Instead, you will be added to the group agreement as soon as your filing information request has been approved. (It may take up to three weeks after the notification authorization is approved.) 2. Fill out, sign and date the required forms in the package. As soon as we have received your request for a CAQH application or approved by the state, we will send you a contract called your participation contract. This usually happens within 10 business days.

If you have provided us with an email address, we will send you the DocuSign secure application contract. (For more information about DocuSign, see below) If not, we will email it to you. Remember: receiving a participation agreement from us does not mean that your application has been approved. In order to shorten the onboarding time line, we send you the agreement for verification while your login application will be verified. You will receive a decision regarding your application separately UnitedHealthcare Critical Illness product will be provided by UnitedHealthcare Insurance Company on the 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 coverage” under the Affordable Care Act and therefore does NOT fulfill the mandate to purchase health insurance.