Get Enrollment Form - Unitedhealthcareonline.com

Filling out the Enrollment Form for UnitedHealthcare can be a straightforward process when approached step by step. This guide provides clear instructions to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the Enrollment Form correctly.

1. Press the ‘Get Form’ button to access the Enrollment Form and open it in the available editing interface.
2. Begin by entering the today's date and the need by date in the designated fields.
3. Provide the patient information, including the patient's name and insurance ID number.
4. Fill in the parent or guardian's name, home phone, alternate phone, and complete address, including city, state, and ZIP code.
5. Enter the date of birth in the format mm/dd/yyyy, and select the sex of the patient.
6. In the medical information section, fill out the ICD codes and diagnoses as required, ensuring to attach any necessary medical records.
7. Answer the questions regarding previous administration of and specify the prior injection site if applicable.
8. Indicate whether there has been significant pain relief from previous injections and whether the pain has recurred.
9. Complete the prescription information by selecting the appropriate medication from the list and providing medication strength, directions, quantity, and number of refills.
10. Input the prescriber information, including name, NPI, address, and contact information.
11. Include insurance information by filling out both primary and secondary insurer details, and remember to fax a copy of the patient’s insurance card, both sides.
12. After completing all sections, review the form for accuracy before saving, downloading, printing, or sharing as needed.

Start filling out your Enrollment Form online today to ensure timely processing.