Request For Participation Form - Identification Information
Please complete this form to request participation with UnitedHealthcare Commercial, Medicare or Medicaid plans.IMPORTANT NOTE:
Be sure to save your information often by clicking “Save and Continue.” All fields are required.
Please make sure you have only ONE Request for Participation Form window open at a time. Working on the same submission in multiple windows will result in processing errors.
This form is for individual care providers only. For a facility (hospital, home health agency, skilled nursing facility, etc.) please call UnitedHealthcare for Health Care Professionals at 877-842-3210. Enter your tax ID number then Credentialing > Medical > Join the Network.
Only submit one form per care provider regardless of the number of specialties or locations. Additional specialties and/or locations will be listed on your Council for Affordable Quality Healthcare (CAQH) or state-mandated application.
Practitioner: the licensed care provider requesting to see UnitedHealthcare members.
Individual National Provider Identifier (NPI) Number: the NPI number for the practitioner requesting to see UnitedHealthcare members.
Date of Birth: the Date of Birth for the practitioner requesting to see UnitedHealthcare members.
Insurance coverage provided by or through UnitedHealthcare Insurance Company,
All Savers Insurance Company, or their affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc.,
UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc.,
UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc.,
UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc.,
OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S.
Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.