Provider Forms

Dental Claim Form

Medical Claim Form (HCFA1500)

Notification Form

Remittance Advice

• Electronic/Paper Remittance Advice Request Form - Please utilize this form to advise us of your desire to receive paper or electronic remittance advice for your claims.

General Information

• Medical Info Required for Notification

• UnitedHealthcare - Medical & Drug Policies and Coverage Determination Guidelines