| | United HealthCare Forms |
| | All forms and plan descriptions are in portable document format (PDF).
 |
| | Some forms are available for download in Spanish.
Click the language to download the form. |
| | Form Type: Medical |
| | Form Name | Form Description
|
| |
1099 Independent Contractors Form
English
() | 1099 Independent Contractors Form |
| |
2008 Plan Overview
English
() | Overview of plans for 2008 |
| |
Common Ownership Form
English
(47 kb) | Common Ownership Form |
| |
Continuation of Group Health Form
English
(232 kb) | Continuation of Group Health Form |
| |
Dual Option Employee Plan Selection Form
English
(46 kb) | For Groups choosing Dual Option Plan |
| |
Employee Enrollment Form
English
Spanish
(92 kb) | Employee Enrollment Form |
| |
Employee Enrollment Form for Additional Dependents
English
(17 kb) | Employee Enrollment Form for Additional Dependents |
| |
Employer Application for Groups
English
(164 kb) | Employer Application for Groups |
| |
Health Allies Application for Groups
English
(110 kb) | Health Allies Application for Groups |
| |
Health Allies Brochure
English
(71 kb) | Health Allies Brochure |
| |
Health Allies Enhanced Enrollment Form
English
(77 kb) | Health Allies Enhanced Enrollment Form |
| |
Health Allies Enrollment Form
English
(78 kb) | Health Allies Enrollment Form |
| |
Health Allies Implementation Checklist
English
(133 kb) | Health Allies Implementation Checklist |
| |
Health Insurance Claim Form
English
(22 kb) | Health Insurance Claim Form |
| |
HIPAA Disclosure Authorization Form
English
(66 kb) | HIPAA Disclosure Authorization Form |
| |
HSA Exante Employee Application
English
(60 kb) | HSA Exante Employee Application |
| |
Mail Order Prescription Form
English
() | Mail Order Prescription Form |
| |
Prescription Drup Reimbursement Form
English
(132 kb) | Prescription Drup Reimbursement Form |
| |
Previous Health Benefit Coverage Affidavit
English
(66 kb) | Previous Health Benefit Coverage Affidavit |
| |
PRIME Enrollee Dependent Level Medicare Change Form
English
(70 kb) | PRIME Enrollee Dependent Level Medicare Change Form |
| |
Privacy Policy and Practices
English
(32 kb) | Privacy Policy and Practices |
| |
Produce and benefit selection form
English
() | Produce and benefit selection form for small business |
| |
Request for Enrollment of Common Law Spouse
English
() | Affidavit of common law marriage |
| |
Required Tax Documentation
English
(96 kb) | Required Tax Documentation |
| |
Scheduled Direct Debit Authorization
English
(45 kb) | Scheduled Direct Debit Authorization |
| |
UHC Employer Application
English
() | Employer application for enrolling new groups 1-1-08. |
| |
UHC Small Business Portfolio
English
() | Plan comparison of all UHC small group health plans. |
| | Form Type: Dental/Vision |
| | Form Name | Form Description
|
| |
Dental Claim Form
English
(78 kb) | Dental Claim Form |
| |
