Member forms

If you can’t find the form or document you’re looking for below, sign in to your member site to find more.

Sign in to see forms for your health plan

• Plan through your employer
• Medicare plan
• Medicaid plan
• See more sign in options

Download forms here

Reimbursement and claim forms

Medical reimbursement and claim forms

To request COVID-19 reimbursement, please select one of the COVID-19 Testing/Vaccine Administration reimbursement types. This form can also be used for foreign care, DME, physical therapy and other qualified services or purchases. Note: This form is for individuals that currently have, or previously had, a UnitedHealthcare insurance plan and sign in using myuhc.com. This form cannot be used by UnitedHealthcare Community Plan members, Medicare & Retirement members, UnitedHealthcare West, Expat, or some other members with insurance through their employer or an individual plan.

Dental claim form

Note: This form cannot be used by UnitedHealthcare Medicare Advantage members (including UnitedHealthcare Dual Complete plan members)

Flexible Spending Account (FSA) forms

• Flexible Spending Account (FSA) request for health care reimbursement (pdf)
• Flexible Spending Account (FSA) request for dependent care reimbursement (pdf)

Health Reimbursement Account (HRA) forms

Health Savings Account (HSA) forms

Sweat Equity® Reimbursement forms

• Sweat Equity® Reimbursement Form for New York UnitedHealthcare small group (1-100) and large group (101+) members, excluding Empire Plan – English (pdf)
• Sweat Equity® Reimbursement Form for New York for UnitedHealthcare small group (1-100) and large group (101+) members, excluding Empire Plan – Spanish (pdf)
• Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members, excluding Empire Plan – English (pdf)
• Sweat Equity® Reimbursement Form for New Jersey UnitedHealthcare large group (51+) members, excluding Empire Plan – Spanish (pdf)

*Oxford members, please look to the Oxford health plan forms (drawer below) to obtain your Sweat Equity Reimbursement Form.

Appeals and grievance medical and prescription drug request forms

California

California appeals and grievance forms

You have the right to file a formal grievance about any of your medical care or services. You may submit a grievance for a denial of a service or denied claims within 180 calendar days of your receipt of an initial determination through our Appeals and Grievances Department. UnitedHealthcare will acknowledge receipt within 5 calendar days and provide an answer within 30 calendar days for a standard review. If your problem is urgent, UnitedHealthcare must give you a decision within 3 calendar days. Your problem is urgent if there is a serious threat to your health that must be resolved quickly. You may file a grievance by mail, fax or by submitting a GRIEVANCE FORM online. If you have any questions, or prefer to file this grievance orally, please feel free to call UnitedHealthcare Customer Service or the number on the back of your ID card.

California grievance forms for UnitedHealthcare Benefits Plan of California

• GRIEVANCE FORM (pdf)
• Español (pdf)
• 中文 (pdf)

California grievance forms for UnitedHealthcare of California SignatureValue™ HMO

• GRIEVANCE FORM (pdf)
• Español (pdf)
• 中文 (pdf)

Minnesota

Minnesota appeals and grievance forms

• MN Managed Health Care Plans UnitedHealthcare of Illinois
• MN Insurance Plans United Healthcare Insurance Company

General

Note: Complete and submit this form for appeals or grievances for medical or pharmacy services you received. This excludes Community Plan members, Medicare & Retirement members, UHC West, Surest and some members with insurance through their employer or individual plan. Before you start, make sure you have all applicable documents from your provider. Providing supporting documents will help with the appeal review.

Tax, legal and appeals forms

IRS Forms 1095-A, 1095-B and 1095-C

There are 3 types of health insurance information forms you may need to file your taxes.

Form 1095-A is the Health Insurance Marketplace Statement. You'll receive this form if you enrolled in coverage through the Marketplace.

Form 1095-B is a form you may need when you file your taxes, depending on the law in your state.

Most fully insured UnitedHealthcare members will not automatically receive a paper copy of Form 1095-B due to a change in the tax law. However, Form 1095-B will continue to be available on member websites or by request.

Here are the ways to get a copy of your Form 1095-B:

• Sign in to your member account to view and/or download and print a copy of the form
• Call the number on your member ID card or other member materials
• Complete the 1095B Paper Request Form and email it to your health plan at the email address listed on the form

Call UnitedHealthcare using the number on your member ID card or other member materials if you have questions about this form.

Form 1095-C is a form you may receive from your employer if get your health plan through work.

Learn more about these health care information forms for individuals from the Internal Revenue Service.

Certificate of Coverage (COC) or Proof of Lost Coverage (POLC) form

Use this form to request Certificate of Coverage (COC) document(s) when coverage is still active or to request Proof of Lost Coverage (POLC) document(s) when coverage is no longer active. This form is for individuals that currently have or previously had insurance through their employer or an individual plan through UnitedHealthcare and sign in using myuhc.com. This form should not be used by UnitedHealthcare West, Oxford, Expat, Empire or some members with insurance through their employer or an individual plan.