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Medical Claim Form - Digital Format PDF icon (digitally complete form, then print)
Medical Claim Form - Non-Digital Format PDF icon (print form, then complete by hand)
Flexible Spending Account Healthcare Claim Form (PDF)
Flexible Spending Account Dependent Care Claim Form (PDF)
Health Reimbursement Account Claim Form (PDF)
International Claim Form (PDF)
HSA Forms
Sweat Equity Program for UnitedHealthcare NY Small Group (1-100) and NJ Large Group (51+) Members (PDF)
Sweat Equity Claim Form for UnitedHealthcare NY Small Group (1-100) and NJ Large Group (51+) Members (PDF)
Sweat Equity Program for Oxford members (PDF)
Sweat Equity Claim Form for Oxford members (PDF)
Oxford Mail Order Form
Oxford Prescription Reimbursement Claim Form
BRS COEs for CT Oxford Members
Physician Referral Form

California Continuity of Care Forms for SignatureValue Managed Care Members:

English (PDF)
Español (PDF)
中文 (PDF)

Oklahoma, Oregon, Texas and Washington Continuity of Care Form for SignatureValue Managed Care Members:

English (PDF)

CALIFORNIA GRIEVANCE FORMS FOR SIGNATUREVALUE MANAGED CARE MEMBERS:

ENGLISH (PDF)
ESPANÓL (PDF)
中文 (PDF)

California Fully-Insured products: Choice, Choice Plus, Non-Differential ("Non-Diff" or "Options PPO"), Select and Select Plus, Core; Core Essentials Network, and Navigate.

Continuity of Care - English (PDF)
Continuity of Care - Spanish (PDF)
Continuity of Care - Chinese (PDF)

Dental:

UnitedHealthcare Dental Change form/brochures (PDF)
Dental Evidence of Coverage manual CA brochure (PDF)
DE Signature Value Dental 160 brochure (PDF)
Nominate a Dentist (PDF)
Dental Claim Form (Online)
KY Complaint, Grievance and Appeals (PDF)
MA External Grievance Review Form (PDF)
MA External Grievance Review Form Espanol (PDF)
Dental Grievance Form English and Espanol (PDF)
Dental Grievance Form 中文 (PDF)
NV Individual EOC (PDF)
NV Individiual FAQ (PDF)
CA Individual Brochure & Form (PDF)
CA Individual EOC (PDF)
CA Individual Change Form (PDF)
CA Fed Employee Brochure & Form (PDF)
CA Fed Employee EOC (PDF)
CA Fed Employee Change Form (PDF)

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