Claim Information Form - United Healthcare Student Resources

CLAIM INFORMATION FORM - UNITEDHEALTHCARE STUDENTRESOURCES

INSURED INFORMATION

Last Name:

First Name:

Middle Initial:

Gender (M/F)

SR ID#(

Home phone #:

Date of Birth (mm/dd/yy):

Email address:

refer to your ID card

(

)

Mailing address:

P.O. Box:

City:

State:

ZIP Code:

PATIENT INFORMATION

(IF DIFFERENT FROM INSURED)

Gender (M/F)

Last Name:

First Name:

Middle Initial:

Mailing address:

P.O. Box:

City:

State:

ZIP Code:

Home phone #: (

)

Date of Birth

(mm/dd/yy)

Patient’s relationship to student:

 Self

 Spouse

 Child

 Other

(please explain)

ACCIDENT INFORMATION

 Auto

 IC Sport

 Intramural Sport

 Interscholastic Sport

 Work

 Other

Type of Accident:

Date Occurred:

Type of Sport (Football, track, etc.):

Details of Accident:

INJURY / SICKNESS INFORMATION

 Yes

 No If Yes, and if you were treated for it, please provide information:

Have you suffered the same or a similar condition in the past?

Physician’s Name:

Physician’s Address:

Date Treated:

I hereby authorize any physician, hospital, or other medical provider to release any information regarding the medical history, treatment, or

benefits payable for this claim to United Healthcare Insurance Company. A photocopy of this authorization shall be as valid as the original.

Insured’s Signature:

Date:

OTHER INSURANCE INFORMATION

Is the patient covered by another insurance plan?  Yes

 No

If you checked “Yes”, please complete the section below.

Name of person carrying other insurance:

Subscriber #:

Name of other insurance carrier:

Other Insurance Policy #:

Other Insurance Phone #:

Policyholder Date of Birth(

mm/dd/yy

NOTICE:

PLEASE REFER TO FRAUD WARNING STATEMENT(S) INCLUDED ON THE SECOND PAGE OF THIS FORM.

Insured’s Signature:

Date:

STUDENT HEALTH CENTER REFERRAL

A Referral was received:

Health Center Closed:

This was an

I was more than 50 miles from campus:

Other (please explain):

Emergency:

 Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

Guidelines for Submitting Claims to UnitedHealthcare StudentResources



Bills must include diagnosis code, procedure code, service date and cost. Clip, do not staple, all bills to this completed form.



For prescription claims, provide receipt or computer printout from the Pharmacy which includes Medicine name, date dispensed and price with

your name, address and SR ID#. A claim form is not required.

Mail claim to: UnitedHealthcare StudentResources , P. O. Box 809025, Dallas, TX 75380-9025 (This is listed on your ID card)

or Email : A scanned copy of the claim to

Fax claim to: 469-229-5625

Page 1 of 2

UHCSR Claim Form (Rev 02/16/2015)

Claim Information Form - United Healthcare Student Resources - 2015

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