Forms

Medical Claim Form

Choice Plus members, send your completed claim form to:
UnitedHealthcare
P.O. Box 740809
Atlanta, GA 30374

Disabled Dependent Form

Complete this form and submit to UnitedHealthcare to request a coverage extension for a disabled child age 26 or older who otherwise meets the dependent children definition and these requirements are met:

• The child is severely disabled by prolonged physical or mental incapacity;
• The child became disabled prior to reaching age 26;
• The child was covered by the plan prior to reaching age 26, or, if older than age 26, loses coverage under a parent’s/guardian’s plan. In the event of loss of coverage, proof of prior coverage must be provided;
• The child is unmarried and you or your spouse/domestic partner provide more than 50% of his or her support because he or she is unable to earn a living; and
• Disabled dependent status is approved by UnitedHealthcare on behalf of U.S. Bank. 

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