Forms Archives - UHCSR International

Forms – Palm Beach Atlantic University

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – Albion College

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – Quinnipiac University

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – University of Montevallo

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – University of Montevallo

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – Jacksonville State University

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – University of North Alabama

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – United Christian Academy

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – Kettering College

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

Forms – Webster University

Claim form*

Standard form to provide notice of medical/prescription and/or provide details on requests for additional information.

Authorization to use or disclose health information

This form allows an insured to provide specific instructions to UnitedHealthcare Student Resources International for use or disclosure of protected health information for a particular purpose.

Personal Representative Appointment*

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare Student Resources International.

*You can submit the form online by signing in to My Account.

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Archives

Forms – Palm Beach Atlantic University

Forms – Albion College

Forms – Quinnipiac University

Forms – University of Montevallo

Forms – University of Montevallo

Forms – Jacksonville State University

Forms – University of North Alabama

Forms – United Christian Academy

Forms – Kettering College

Forms – Webster University

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