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Forms

Golden Rule Insurance Company, an affiliate of UnitedHealthcare, is excited to announce the launch of its Web site provider portal, www.MyUHOne.com/provider. Providers - please visit this user-friendly tool that offers such features as Provider Registration, Eligibility Information, Claim History, Plan Benefit Search Capabilities, EOB Information, Code Review Information, Provider News, FAQs and UnitedHealthcare Children's Foundation Information.

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Health Insurance 34535-G-0308

Authorization for Disclosure of Personal Information (General)

Health Insurance 34534-0503

Authorization for Disclosure of Specific Personal Information (One occurrence only)

Health Insurance 1044-G-1111

Authorization To Obtain & Disclose Information

Health Insurance 1044KY-G-1111

Authorization To Obtain & Disclose Information (KY)

Health Insurance 1044NC-G-1111

Authorization To Obtain & Disclose Information (NC)

Health Insurance 1044OK-G-1111

Authorization To Obtain & Disclose Information (OK)

Health Insurance 36231-0709

Authorization to Obtain and Disclose Non-Medical Information (NC)

Health Insurance CABCA2-G-1109

Claim Form for AR, AZ, CA, LA, TX

Health Insurance CABCO2-G-1109

Claim Form for CO

Health Insurance CABFL2-G-1109

Claim Form for FL

Health Insurance CABIN2-G-1109

Claim Form for IN and NH

Health Insurance CABKY2-G-1109

Claim Form for KY

Health Insurance CABNJ2-G-1109

Claim Form for NJ

Health Insurance CABNM2-G-1109

Claim Form for NM

Health Insurance CABOK2-G-1109

Claim Form for OK

Health Insurance CABPA2-G-1109

Claim Form For PA

Health Insurance CABST2-G-1109

Claim Form Standard (for all other states)

Health Insurance 279E-G-1211

CO Prescreening Questionaire

Health Insurance 37444-G-14-0909

Disclosure of Dental Coverage (IA)

Health Insurance 37444-G-1008

Disclosure of Dental Coverage (IL)

Health Insurance 37444-G-17-0609

Disclosure of Dental Coverage (LA)

Health Insurance 39338-G-0311

Disclosure of Dental Coverage (NJ)

Health Insurance 790-1209F

EFT Authorization

Health Insurance 39203-G-0710

Employer Payor for Multiple Applicants Packet

Health Insurance 201E-G-1111

Existing Customer Application for AK

Health Insurance 788D-G-1111

Existing Customer Application for AL

Health Insurance 792D-G-1111

Existing Customer Application for AR

Health Insurance 789D-G-1111

Existing Customer Application for AZ

Health Insurance 865B-G-1111

Existing Customer Application for CA

Health Insurance 601D-G-1111

Existing Customer Application for CO- Assoc. Goup (FACT)

Health Insurance 276E-G-1111

Existing Customer Application for CO- True Individual

Health Insurance 119D-G-1111

Existing Customer Application for CT-Assoc. Group (FACT)

Health Insurance 495D-G-1111

Existing Customer Application for CT-True Individual

Health Insurance 799D-G-1111

Existing Customer Application for DC

Health Insurance 673D-G-1111

Existing Customer Application for DE

Health Insurance 480D-G-1111

Existing Customer Application for FL-Assoc. Group (FACT or NASE)

Health Insurance 836C-G-1111

Existing Customer Application for FL-True Individual

Health Insurance 475C-G-1111

Existing Customer Application for GA-Assoc. Group (FACT)

Health Insurance 197E-G-1111

Existing Customer Application for GA-True Individual

Health Insurance 870B-G-1111

Existing Customer Application for HI/MT/NH

Health Insurance 793D-G-1111

Existing Customer Application for IA

Health Insurance 815C-G-1111

Existing Customer Application for ID

Health Insurance 208E-G-1111

Existing Customer Application for IL

Health Insurance 099D-G-1111

Existing Customer Application for IN

Health Insurance 480C-G-1111

Existing Customer Application for KS - Assoc Group

Health Insurance 277E-G-1111

Existing Customer Application for KS - True Individual

Health Insurance 247D-1107

Existing Customer Application for KY - Association Group (FACT)

Health Insurance 490D-G-1111

Existing Customer Application for KY - True Individual

Health Insurance 492D-U-1111

Existing Customer Application for LA- True Individual (UHIC)

Health Insurance 724D-G-1111

Existing Customer Application for LA-Assoc. Group (FACT)

Health Insurance 671D-G-1111

Existing Customer Application for LA-True Individual

Health Insurance 863B-G-1111

Existing Customer Application for MA, OR, UT

Health Insurance 800D-G-1111

Existing Customer Application for MD - Assoc Group (FACT)

Health Insurance 801D-G-1009

Existing Customer Application for MD - True Individual

Health Insurance 721C-G-1111

Existing Customer Application for ME

Health Insurance 794D-G-1111

Existing Customer Application for MI

Health Insurance 726C-G-1111

Existing Customer Application for MN

Health Insurance 795D-G-1111

Existing Customer Application for MO

Health Insurance 790D-G-1111

Existing Customer Application for MS

Health Insurance 278E-G-1111

Existing Customer Application for NC

Health Insurance 819C-G-1111

Existing Customer Application for ND

Health Insurance 791D-G-1111

Existing Customer Application for NE

Health Insurance 199E-G-1111

Existing Customer Application for NM

Health Insurance 880B-G-1111

Existing Customer Application for NV- Assoc. Group (FACT)

Health Insurance 672D-G-1111

Existing Customer Application for NV-True Individual

Health Insurance 797D-G-1111

Existing Customer Application for OH

Health Insurance 796D-G-1111

Existing Customer Application for OK

Health Insurance 798D-G-1111

Existing Customer Application for PA-Assoc. Group (FACT or NASE)

Health Insurance 803D-G-1111

Existing Customer Application for PA-True Individual

Health Insurance 804D-G-1111

Existing Customer Application for SC-Assoc. Group (FACT)

Health Insurance 806D-G-1111

Existing Customer Application for SC-True Individual

Health Insurance 200E-G-1111

Existing Customer Application for SD

Health Insurance 094D-G-1111

Existing Customer Application for TN

Health Insurance 808D-G-1111

Existing Customer Application for TX- True Individual

Health Insurance 807D-G-1111

Existing Customer Application for TX-Assoc. Group (FACT)

Health Insurance 198E-G-1111

Existing Customer Application for VA

Health Insurance 235E-G-1111

Existing Customer Application for WI

Health Insurance 810D-G-1111

Existing Customer Application for WV- True Individual

Health Insurance 493D-G-1111

Existing Customer Application for WV-Assoc. group (FACT)

Health Insurance 202E-G-1111

Existing Customer Application for WY

Health Insurance 002C-1209

Health Insurance Certification for AK, DE, MD, OK, TN, VA, WV, WI

Health Insurance 953B-799

Health Insurance Certification for AL, AR, AZ, DC, FL, IL, IN, IA, KS, KY, MI, MO, MS, NM, PA, SC, TX

Health Insurance 063B-799

Health Insurance Certification for CO

Health Insurance 120D-0405

Health Insurance Certification for CT & NM

Health Insurance 074C-1209

Health Insurance Certification for GA, NE, OH

Health Insurance 520D-0408

Health Insurance Certification for SD

Health Insurance 193E(A)-G-0911

IL Universal Application Administration Forms

Health Insurance 36749-G-0710

List Bill Packet

Health Insurance 155X-1209

OptumHealthBank HSA Application

Health Insurance 31237-G-1110

Qualified Medical Expenses

Health Insurance 206E(A)-G-0611

WI Universal Application Administrative Forms

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.