Forms Archives - Page 2 of 3 - UHCSR International

Forms – California State University- Bakersfield

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 – St. John’s 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 – Virginia Commonwealth 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 – Andrews Osborne 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 – Eurasia

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 – Tennessee Board of Regents

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 New Orleans

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 – Borden Perlman

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 – Global School Access

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.

Register for Camp

Archives

Forms – California State University- Bakersfield

Forms – St. John’s University

Forms – Virginia Commonwealth University

Forms – Andrews Osborne Academy

Forms – Eurasia

Forms – Tennessee Board of Regents

Forms – University of New Orleans

Forms – University of Montevallo

Forms – Borden Perlman

Forms – Global School Access

Legal

Contact