Forms

Claim Information Form

Please download this form if you’ve received a request asking for more information regarding a claim submitted by your doctor, or if you would like to speed up the claim process. By providing the injury/sickness information we will be able to process your claim more accurately and efficiently.

Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025

Or fax it to:
469-229-5625
 

Dental Insurance Enrollment Form

This is the form that you will use to sign up for the School Dental Insurance plan.  It will show you the rates and Coverage Periods.  To download the current enrollment form, please visit the STUDENT / DEPENDENT DENTAL ENROLLMENT CENTER.

Health Insurance Continuation Enrollment Form

This is the form that you will use to continue the School Injury and Sickness plan. It will show you the rates, coverage periods and any optional coverages available to you. This enrollment form allows you to continue your coverage up to three (3) months.

Health Insurance Enrollment Form

This is the form that you will use to sign up for the School Injury and Sickness plan. It will show you the rates, coverage periods and any optional coverages available to you. To download the current enrollment form, please visit the Student/Dependent Enrollment Center.

Vision Insurance Enrollment Form

This is the form that you will use to sign up for the School Vision Insurance plan.  It will show you the rates and coverage periods.  To download the current form, please visit the STUDENT / DEPENDENT VISION ENROLLMENT CENTER.

Medical Claim Form

This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:

• Clip, do not staple, all bills to the completed form.
• Make sure all bills or itemized receipts indicate a diagnosis code, procedure code, date of service, cost, and the provider’s tax ID number.
• Mail claim to: UnitedHealthcare StudentResources P. O. Box 809025 Dallas, TX 75380
• OR Fax claim to: 469-229-5625

Pharmacy Claim Form

This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:

Medco Health Solutions, Inc.
P.O. Box 14711
Lexington, KY 40512
 

Privacy Notice

This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.

Specific Case Authorization Form

If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.

United Health Allies Discount Services

This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.

Yearly Authorization Form

If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative, throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.

To view or print the PDF files, you'll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms, you might need to download the most recent version of Adobe Reader.