Customer Forms


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Customer Service:
1-800-657-8205

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	Authorization for Disclosure of Personal Information (General)
	Authorization for Disclosure of Specific Personal Information (One occurrence only)
	Authorization to Obtain & Disclose Information
	Authorization to Obtain & Disclose Information (KY)
	Authorization To Obtain & Disclose Information (NC)
	Authorization to Obtain & Disclose Information (NM)
	Authorization to Obtain & Disclose Information (OK)
	Authorization to Obtain and Disclose Non-Medical Information (NC)
	Change of Beneficiary Agreement
	Claim Form for AR, AZ, CA, LA, TX
	Claim Form for CO
	Claim Form for FL
	Claim Form for IN and NH
	Claim Form for KY
	Claim Form for NJ
	Claim Form for NM
	Claim Form for OK
	Claim Form For PA
	Claim Form Standard (for all other states)
	Disclosure of Dental Coverage (IA)
	Disclosure of Dental Coverage (IL)
	Disclosure of Dental Coverage (LA)
	EFT Authorization
	Employor Payor for Multiple Applicants Packet
	Existing Customer Application for AL
	Existing Customer Application for AR
	Existing Customer Application for AZ
	Existing Customer Application for CA
	Existing Customer Application for CO - Association Group (FACT)
	Existing Customer Application for CO - True Individual
	Existing Customer Application for CT - Association Group (FACT)
	Existing Customer Application for CT - True Individual
	Existing Customer Application for DC
	Existing Customer Application for DE
	Existing Customer Application for FL - Association Group (FACT or NASE)
	Existing Customer Application for FL - True Individual
	Existing Customer Application for GA - Association Group (FACT)
	Existing Customer Application for GA - True Individual
	Existing Customer Application for HI, MT, & NH
	Existing Customer Application for IA
	Existing Customer Application for ID
	Existing Customer Application for IL
	Existing Customer Application for IN
	Existing Customer Application for KS
	Existing Customer Application for KY - Association Group (FACT)
	Existing Customer Application for KY - True Individual
	Existing Customer Application for LA - Association Group (FACT)
	Existing Customer Application for LA - True Individual
	Existing Customer Application for MA, OR, RI, and UT
	Existing Customer Application for MD - Association Group (FACT)
	Existing Customer Application for MD - Association Group (NASE)
	Existing Customer Application for MD - True Individual
	Existing Customer Application for ME
	Existing Customer Application for MI
	Existing Customer Application for MN
	Existing Customer Application for MO
	Existing Customer Application for MS
	Existing Customer Application for NC
	Existing Customer Application for ND
	Existing Customer Application for NE
	Existing Customer Application for NM
	Existing Customer Application for NV
	Existing Customer Application for OH
	Existing Customer Application for OK
	Existing Customer Application for PA - Association Group (FACT or NASE)
	Existing Customer Application for PA - True Individual
	Existing Customer Application for SC - Association Group (FACT)
	Existing Customer Application for SC - Association Group (NASE)
	Existing Customer Application for SC - True Individual
	Existing Customer Application for TN
	Existing Customer Application for TX - Association Group (FACT or NASE)
	Existing Customer Application for TX - True Individual
	Existing Customer Application for VA
	Existing Customer Application for WI
	Existing Customer Application for WV - Association Group (FACT)
	Existing Customer Application for WV - Association Group (NASE)
	Existing Customer Application for WV - True Individual
	Health Insurance Certification for AK, DE, MD, OK, TN, VA, WV, WI
	Health Insurance Certification for AL, AR, AZ, DC, FL, IL, IN, IA, KS, KY, MI, MO, MS, NM, PA, SC, TX
	Health Insurance Certification for CO
	Health Insurance Certification for CT & NM
	Health Insurance Certification for GA, NE, OH
	Health Insurance Certification for SD
	Heart Murmur Inquiry
	List Bill Packet
	OptumHealthBank HSA Application
	Qualified Medical Expenses

IRS W-9 Form - Click this link to go to the IRS Web site to download the W-9 Request for Taxpayer Identification and Certification form.

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Not intended for use in New Mexico.

UnitedHealthOne is a brand name used for products underwritten, administered, and/or provided by:
Golden Rule Insurance Company (Indiana domiciled, CA certificate of authority number 4407),
American Medical Security Life Insurance Company (Wisconsin domiciled, CA certificate of authority number 08079),
PacifiCare Life and Health Insurance Company(Indiana domiciled, CA certificate of authority number 5813),
PacifiCare Life Assurance Company (Colorado domiciled, CA certificate of authority number 5814),
Oxford Health Insurance, Inc.,
Oxford Health Plans (NJ), Inc., or
UnitedHealthcare Insurance Company.
UnitedHealthcare Services, Inc.,
Dental Benefit Providers, Inc.,
Spectera, Inc.

Health Insurance plans are medically underwritten and availability varies by state. Coverage may be provided by multiple policies/certificates

Additional Products are provided by:
Careington International Corporation,
EyeMed Vision Care, or
International Medical Group, Inc. (Indiana domiciled)

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