Forms

Health Allies
To download the Health Allies brochure please click here.

Claim Form
Used by you or your doctor, to submit a claim for benefits or a prescription drug reimbursement (for those policies which have MEDCO Rx Discount Program).
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Claim Information Form
If you’ve received requests for more information regarding a claim, complete the claim information form and mail it to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
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Specific Case Authorization Form
This form gives us permission to discuss a specific medical condition you might have with a designated person of your choice.
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Yearly Authorization Form
This form gives us permission to discuss any and all medical conditions you might have with a designated person of your choice, throughout the school year.
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Privacy Notice
This form gives you information on how we handle and protect your privacy regarding any medical condition.
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