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View and download claim forms by following the link to the Global Resources Portal opens in new window and clicking on My Claims.
A Claim Form is a document used to formally request compensation or reimbursement from an insurance company, government agency, or another entity. It outlines the details of the claim, including the nature of the claim, the amount being claimed, and any supporting evidence.
Easily access and download all UnitedHealthcare provider-forms in one convenient location. The UnitedHealthcare Provider Portal allows you to submit referrals, prior authorizations, claims, claim reconsideration and appeals, demographic changes and more.
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GENERAL INSTRUCTIONS. The form is designed so that the name and address (Item 3) of the third-party payer receiving the claim (insurance company/dental benefit plan) is visible in a standard #9 window envelope (window to the left). Please fold the form using the ‘tick-marks’ printed in the margin.
This form is for out-of-network claims ONLY, to ask for payment for eligible health care you have received. To ensure faster processing of your claim, be sure to do the following: If you write on the form, use black or blue ink and print clearly and legibly.
