Loading...Download the United Health Care Medical Claim Form. This form is designed to submit medical claims to United Health Care Insurance Company. It’s also used to acquire reimbursements on initial out of pocket claims.
How To Write
Step 1 – Section A – Guidelines For Submitting Claims to United Health Care –
- Read all of the tips located in section A to assist in completing a successful claim
Step 2 – Section B – Subscriber/Employee Information –
- Subscriber Number or Social Security Number:
- Phone Number
- Employer Name
- Last Name
- First Name
- Middle Initial
- Date of Birth mm/dd/yyyy
- Group Number or ID Card
- Home Address
- New Address (check one)
- City
- State
- Zip Code
- Spouse Last Name
- First Name
- Middle Initial
- Spouse Date of Birth mm/dd/yyyy
Step 3 – Section 3 – Patient Information (if different from Subscriber/Employee) – If you are the subscriber, but this is one of your children or anyone covered on your policy, you will complete this area of the form. If you are the patient, you may skip this portion of the form as you have already provided your information in Section B:
- Subscriber Number or Social Security Number:
- Phone Number
- Employer Name
- Last Name
- First Name
- Middle Inititial
- Date of Birth mm/dd/yyyy
- Group Number or ID Card
- Home Address
- New Address (check one)
- City
- State
- Zip Code
- Spouse Last Name
- First Name
- Middle Initial
- Sex (check one)
- Relationship to Subscriber
- Full Time Student (check yes or no)
- School Name
- School Phone Number (with area code)
Step 4 – Section D – Accident Information If this illness was due to an accident, complete as follows:
- Work Accident (check yes or no)
- Auto Accident (check yes or no)
- Other (yes or no)
- Date of Accident mm/dd/yyyy
- How did the accident happen (explain briefly in the block provided)
Step 5 – Section E – Other Insurance
- Is the patient covered by another insurance plan? (check yes or no)
- If yes, please explain the following information:
- Name of person carrying other insurance
- Date of Birth (mm/dd/yyyy
- Social Security Number
- Name of Insurance Carrier
- Policy Number
- Employer Name
- Read carefully, the information above the signature line – if you understand and agree –
- Signature
- Date mm/dd/yyyy
Step 6 – Section F – Assignment of Benefits –
- Please sign below only if you want United Health Care to pay benefits directly to the provider of medical services
- Signature
- Date mm/dd/yyyy