United Healthcare Military PDF Details

Military members and their families can receive health insurance coverage through United Healthcare Military. This program offers a range of benefits, including preventive care, outpatient services, mental health and substance abuse treatment, and more. In order to take advantage of these benefits, individuals must complete the United Healthcare Military Form. The form is simple to fill out and can be completed online or through the mail. By completing this form, military members and their families can ensure they have access to the best possible health care coverage.

Listed below are some details about united healthcare military. You may find out its length, the actual time required to fill out the form, the blanks you should fill in, and so forth.

QuestionAnswer
Form NameUnited Healthcare Military
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesunited healthcare military veterans tricare referral auth request, uhcmilitarywest com providers referrals, unitedhealthcare military and veterans form, united healthcare military and veterans forms

Form Preview Example

TRICARE Service Request/Notification

Fax referral to: UnitedHealthcare Military & Veterans at: 877-890-9309 Routine 877-890-8203 Urgent

The Military Treatment Facility (MTF) in your area may have Right of First Refusal for this service.

Beneficiary Information

Name: Last

First

M.I.

Gender

DOB: (mm/dd/yyyy)

 

 

 

 

_____ / _____ / ________

 

 

 

 

 

 

Address: Street

Apt. No.

City

 

State

ZIP Code

 

 

 

 

 

 

Contact Phone #:

 

Sponsor SSN:

 

 

 

 

 

 

 

 

 

Requesting Provider Information

 

 

 

 

 

 

 

 

 

 

 

Name:

NPI #:

Address: Street

City

State

ZIP Code

Contact Name: Last

First

Contact’s Department in Facility:

Office Phone #:

Office Fax #:

Provider Rendering Care (Physician/Facility/Agency/Vendor)

Name: (Physician/Facility/Agency/Vendor)

Provider NPI #: (mandatory on form)

Specialty:

 

 

Sub-specialty: (if applicable)

 

 

 

 

 

Reason for Sub-specialty Request:

 

 

Anticipated Date of Service/Admission Date: (mm/dd/yyyy)

 

 

 

_____ / _____ / ________

 

 

 

 

 

 

Address: Street

City

State

ZIP Code

Office Phone #:

Office Fax #:

Servicing Facility Information

Name:

TIN:

Address: Street

City

State

ZIP Code

 

 

 

 

Request Priority: (Please check one)

Routine Urgent

 

 

Service Type: (Please check one)

Specialty Referral Inpatient (Acute, SNF, RTC or Rehab)

 

 

Outpatient (Medical/Surgical or Behavioral Health)

DME, Home health

This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at 1-877-988-9378.

TRICARE West Region Customer Service: 1-877-988-9378 (WEST) • www.uhcmilitarywest.com

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

 

 

Doc#: UHC2467w_20130328

OA100-9116RM1_256

© 2013 United HealthCare Services, Inc.

SR#: 10624774

 

Page 1 of 2

 

 

 

 

 

 

TRICARE Service Request/Notification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admission Type: (Please check one) ER

Direct Admit Elective

 

 

 

 

 

 

Diagnostic Information

 

 

 

 

 

 

 

 

 

Diagnosis:

 

 

ICD-9 Code:

 

 

 

 

 

 

Any Secondary Diagnosis:

 

 

ICD-9 Code:

 

 

 

 

 

Requested Procedures/Services:

 

CPT 4 Code/ HCPCS Code:

 

 

 

 

 

 

Frequency Requested: _____

Daily

Weekly Monthly Other

Duration: ______ Days

Weeks

Months

Number of Visits Requested:

If DME: Purchase Rental

Medical Necessity of Services (Reason for request and/or Explanation of Medical Necessity)

This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at 1-877-988-9378.

TRICARE West Region Customer Service: 1-877-988-9378 (WEST) • www.uhcmilitarywest.com

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

 

 

Doc#: UHC2467w_20130328

OA100-9116RM1_256

© 2013 United HealthCare Services, Inc.

SR#: 10624774

 

Page 2 of 2

 

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