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UnitedHealthcare Medical Claim Form

Please use this form pdficon_small if you live in one of the states listed below and are filing an out-of-network claim yourself. UnitedHealthcare Health Claim Transmittal Form.

Alabama Delaware Louisiana Nebraska Oklahoma Utah
Hawaii Maryland New Mexico South Carolina Virginia
Arkansas Idaho Minnesota North Carolina South Dakota West Virginia
Colorado Indiana Mississippi North Dakota Tennessee Wisconsin
District of Columbia Iowa Montana Ohio Texas Wyoming

For more information, click How to File an Out-of-Network Claim with UnitedHealthcare.