Forms and Documents
Benefit Plans
Medical
Essential Health Benefits (EHB)
Prescription Drug
Vision
Employer Forms
EMPLOYERS
- Employer Application and Certification Form - Small Group
- Employer Application and Certification Form - Large Group
- Census Form - Small Group
- Census Form - Large Group (Excel)
- Authorization for Electronic Funds Transfer (EFT) Employer / COBRA Form
- Instructions for Opening UHA Encrypted Email
- Online & EDI Agreement Authorization and Certification Form
- Dependent Disability
- Group Administrator's Handbook
COBRA
Member Forms
- HIPAA Authorization for Release of Information
- Notice of Privacy Practices
- Preferred Drug List
- Preferred Drug List (condensed)
- Prescription Drug Claim
- Prescription Drug Exception Form
- Pharmacare Prescription Mail Order Flyer
- Prior Authorization for Bariatric Surgery
- Procedures That Are Considered Cosmetic
- Request HDS Subscriber ID Card
- Request Member ID Card
- Screening Checklist for Men
- Screening Checklist for Women
- Services That Require Prior Authorization
- TCOYD Conference Reimbursement Form
Provider Forms
- Advance Financial Notice
- Authorization for Electronic Funds Transfer (EFT) Provider Form
- Claim Reconsideration Request
(Provider Claims Action Request Form) - Concurrent Care Physician Brochure
- How To Initiate An Appeal
- ICD-10 Facts
- Letter to Providers RE: OOS Services for Members
- Medical Payment Policies
- Medical Travel Checklist for Out of State Care
- Long Term Opioid Therapy Consent and Medication Agreement
- Online Provider Services - new account NEW (no paper form required)
- Online Provider Services - new user NEW (no paper form required)
- Online Participating Provider Add Form NEW (no paper form required)
- Online Participating Provider Change Form NEW (no paper form required)
- Online Participating Provider Service Location FormNEW (no paper form required)
- Preferred Drug List
- Preferred Drug List (condensed)
- Prescription Drug Exception Form
- Prior Authorization for Medical Services
- Prior Authorization for Prescription Drugs
- Procedures That Are Considered Cosmetic
- Provider Handbook
- Services that Require Prior Authorization
- Timely Claim Filing Waiver Form
- Vaccination Fee Review Request Form
- W-9
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