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RBG, LOS ANGELES - FORMS
UNITEDHEALTHCARE RELEASED DOWNLOAD
Employer Enrollment
Employer Acceptance Form
8/25/2016   Download
Package Savings
6/29/2016   Download
Scheduled Direct Debit Program Flyer/Form
4/12/2016   Download
UHC Employer Application
4/12/2016   Download
UHC Group Acceptance Form (GAF) 1-1-2016
4/12/2016   Download
UHC Product and Benefit Selection Form - Jan 2016
6/29/2016   Download
UHC Small Business 1–50 Broker Checklist
6/29/2016   Download
Employee Enrollment
Beneficiary Form for Life
7/1/2013   Download
Beneficiary Form for Life - Spanish
4/19/2013   Download
Employee Application
4/14/2016   Download
Employee Change Form 2016
8/25/2016   Download
Employee Dental and Vision Application - English
4/14/2016   Download
Employee Dental and Vision Application - Spanish
4/14/2016   Download
Claims
HIPAA Authorization Form

Description:
Assist members with claims (pdf , 40k)

4/14/2016   Download
Pharmacy Claim Form HMO and PPO
4/14/2016   Download
Other
1099 Independent Contractors Form
4/14/2016   Download
Agent / Agency Agreement Form
4/14/2016   Download
COBRA Notification Form
4/14/2016   Download
Notification of Continuation of Coverage (COBRA)

Description:
Rights under COBRA (pdf , 171k)

4/14/2016   Download
Small Group Medical Plan Change Request Form
6/29/2016   Download
Traveling Through The United States With UHC
7/5/2016   Download
UHC Underwriting Guidelines 2016
6/29/2016   Download