UHC Forms and Applications PDF

This page gives you immediate access to Small Group Health Insurance Forms and Applications for California.

UHC / PacifiCare Forms & Applications For Small Groups - California
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Select a SubCategory... Group Medical \| Dental \| Life & Disability \| Vision
Company	Group Medical - EMPLOYEE	Description	Form #	Rev Date	Fillable
UHC / PacifiCare	Employee Enrollment Form & Waiver of Coverage - English \| Espanol		PCA360949-004	5-2011	Yes
UHC / PacifiCare	Employee Enrollment Form for Additional Dependents for All Fully Insured Groups		100-5221	9-06
UHC / PacifiCare	Change Request Form	For existing enrollees only.	400-3682	7-2011	Yes
UHC / PacifiCare	Health Statement Application		PCA360711-002	5-2011	Yes
Company	Group Medical - EMPLOYER	Description	Form #	Rev Date	Fillable
UHC / PacifiCare	Employer Application		400-3353	4-2011	Yes
UHC / PacifiCare	Group Acceptance / Change Form		400-3658	11-2011	Yes
Company	Group Medical - OTHER	Description	Form #	Rev Date	Fillable
UHC / PacifiCare	Accidental Dismemberment Statement of Claim for Benefits Form		042-1043	10-05
UHC / PacifiCare	Benefit Modification Request Form - Employer		400-3744	1-2010	Yes
UHC / PacifiCare	Claim Form - Health		13404	1-2010
UHC / PacifiCare	Claim Form - Health Employee CA			1-2010
UHC / PacifiCare	Claimant Statement for STD and LTD
UHC / PacifiCare	Common Ownership Form for Groups Up to 50			3-06
UHC / PacifiCare	Compensation Assignment Form and Instructions
UHC / PacifiCare	Customer Issue Submission Form		100-7177	6-06
UHC / PacifiCare	Customer Request for Alternative Renewal Quotes Groups Up to 50			3-04
UHC / PacifiCare	Direct Debit Authorization Form		PCA325730-000	6-07
UHC / PacifiCare	Direct Deposit Form and Instructions
UHC / PacifiCare	Disclosure Authorization Form		AUTH-UNI-011504
UHC / PacifiCare	Enrollment Application/Change/Cancellation Request		400-2572	8-06
UHC / PacifiCare	eServices Scheduled Direct Debit - Employer		100-8513	3-08
UHC / PacifiCare	Group Reporting Form - Employer (PacifiCare Only Plans)		400-2800	3-09	Yes
UHC / PacifiCare	Health Addendum - Employer		400-2756	3-06
UHC / PacifiCare	Health Statement Form		400-2757	11-06
UHC / PacifiCare	HRA Application - ProcessWorks Inc
UHC / PacifiCare	HRA Bank Change Form		100-6809	1-07
UHC / PacifiCare	HRA Benefit Form		100-6808	1-07
UHC / PacifiCare	HRA Enrollment Worksheet		M39386	6-06
UHC / PacifiCare	HRA Worksheet		M39386	6-06
UHC / PacifiCare	Independent Contractors Paid by 1099 Form		1099	12-05
UHC / PacifiCare	Joint Health and Life Employer Application		400-2755	4-06
UHC / PacifiCare	Life Beneficiary Designation Form		042-1013	11-06
UHC / PacifiCare	Life Disability PRIME EOI Form for Enrollees and Dependents		655-1599	10-07
UHC / PacifiCare	Life Notice of Claim Accelerated Benefit		042-1205	10-05
UHC / PacifiCare	Medicare Status Change Form for Enrollees and Dependents
UHC / PacifiCare	Online Payment Remittance Form
UHC / PacifiCare	Pharmacy Reimbursement Claim		100-7297	5-06
UHC / PacifiCare	Prescription Drug Reimbursement Claim Form		100-7297	5-06
UHC / PacifiCare	PRIME New Business 2-99 Enrollment Spreadsheet			6-07
UHC / PacifiCare	Product Benefit Selection Form		400-3548	3-2010	Yes
UHC / PacifiCare	Scheduled Direct Debit Authorization Form for Fully insured Groups 1-150		100-8513 PRIME	2-08
UHC / PacifiCare	Select HRA Application Group Size 2-99
UHC / PacifiCare	Transition of Care Form		100-1342	6-09
UHC / PacifiCare	United Advantage Agency Administrator Add/Removal for Agency Principals/Owners
UHC / PacifiCare	United eServices Agency Administrator Add/Removal for Agency Principals/Owners
Company	Group Medical - Large Groups 51+	Description	Form #	Rev Date	Fillable
UHC / PacifiCare	Enrollment Form - groups over 50 employees	For groups over 50 employees	400-2572	8-06
UHC / PacifiCare	Employee Enrollment Form for CA Groups Over 50 Employees		400-2572	10-05
UHC / PacifiCare	Scheduled Direct Debit Authorization Form for Fully insured Groups 150plus		100-8513 ACIS	2-08
Select a SubCategory... Group Medical \| Dental \| Life & Disability \| Vision
Company	Dental		Form #	Rev Date	Fillable
UHC / PacifiCare	Employee Dental Enrollment Form		100-2659	10-05	Yes
UHC / PacifiCare	Employer Dental Application		D-APP-CA	9-05	Yes
UHC / PacifiCare	Dental Claim Form		100-2414	3-03	Yes
Company	Life Insurance		Form #	Rev Date	Fillable
UHC / PacifiCare	Disability and Life uBuy Employer Application UHIC Trust		LASD-APP	5-03
UHC / PacifiCare	Life Beneficiary Form		042-1013	11-03
UHC / PacifiCare	Life Notice of Claim Form		042-1205	10-05
UHC / PacifiCare	Life and Disability EOI Form for CA Groups 2-99		655-1599	10-07
Company	Vision		Form #	Rev Date	Fillable
UHC / PacifiCare

< Go Back OR view forms & apps for: Aetna \| American Fidelity \| Anthem Blue Cross \| Blue Shield \| California Choice \| coPower \| First Horizon \| The Hartford \| Health Net \| HSA Bank HSA California \| Independence American \| Kaiser \| Kaiser Choice Solution \| New Dental Choice \| Premier Access \| SeeChange \| Sharp \| Sterling HSA The Standard \| UHC / PacifiCare \| Unum \| Western Health Advantage