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Medical Claim Form

Choice Plus members, send your completed claim form to:
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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Transition of Care

If you’re pregnant or receiving certain services – like select cancer therapies, end-stage renal dialysis or a transplant – and your provider isn’t in the network, you temporarily may be able to continue with that provider at the network benefit level. Download and complete the UnitedHealthcare Transition of Care form below and send it to UnitedHealthcare to see if you qualify for Transition of Care.

UnitedHealthcare Transition of Care Form