View Forms and Documents
Use the links below to print/view copies of our most frequently used forms. If you have questions, please contact Customer Care at 1(866) 265-5983 or Provider Relations at UniveraPR@Univerahealthcare.com.
- Disclosure of Ownership and Controlling Interest StatementOpen a PDF
- DME Upgrade FormOpen a PDF
- Eyewear Promotional Offer Acknowledgement and AgreementOpen a PDF
- Home Health Care Recertification FormOpen a PDF
- Member Consent for Provider Representation During Appeal or Complaint ProcessOpen a PDF
- New York Health Care Proxy formOpen a PDF
- New York Health Care Proxy form (Spanish)Open a PDF
- PCP Selection Form (online - Recommended) or PCP Selection FormOpen a PDF
- Prenatal Incentive Program Form (online - Recommended) or Prenatal Incentive Program FormOpen a PDF
- Confirmation of Pregnancy FormOpen a PDF
- Easy Care Referral FormOpen a PDF
- GroupTherapyProposalsOpen a PDF
- MRI/MRA, CT/CTA & Nuclear Cardiology FAX Request FormOpen a PDF
- Medicare Advantage Dental Benefit Plan Year 2023Open a PDF
- Non-Emergent Left Heart Cardiac Catheter Preauthorization FormOpen a PDF
- PET FAX Request FormOpen a PDF
- Preauthorization for Medical Necessity FormOpen a PDF
- Referral FormOpen a PDF
- Request for Grievance or Appeal FormOpen a PDF
- UM Initial Determination Timeframes - Commercial ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicaid & Safety Net ProductsOpen a PDF
- UM Initial Determination Timeframes - Medicare ProductsOpen a PDF
- Claim Adjustment or Retraction Request FormOpen a PDF
- APC Pricing Dispute FormOpen a PDF
- APG Pricing Dispute FormOpen a PDF
- Billing Guidance Exceptions for Non-Enrolled Prescribers and PharmaciesOpen a PDF
- Claims Status Request FormOpen a PDF
- DRG Review Request Inquiry FormOpen a PDF
- Indemnity System Remittance Field DescriptionsOpen a PDF
- Managed Care System Remittance Field DescriptionsOpen a PDF
- Managed Care System Remittance Explanatory CodesOpen a PDF
- Request for Timely Filing ReviewOpen a PDF
- Tips for Accurate and Complete CodingOpen a PDF
- Analysis and Recovery Audit - Provider Request for Review FormOpen a PDF
- Waiver of Liability StatementOpen a PDF
- Two-Day Notification and Initial Treatment PlanOpen a PDF
- Adult Behavioral Health (BH) Home and Community-Based Services (HCBS): Prior and/or Continuing Authorization Request FormOpen a PDF
- Authorization Release FormOpen a PDF
- Authorization Release Form - (Spanish)Open a PDF
- Behavioral Health Outpatient Treatment Request Form
- Behavioral Health Procedure Codes Requiring Preauthorization
- Children and Family Treatment & Support Services Intake FormOpen a PDF
- Children's Home and Community-Based Services Intake Form Open a PDF
- Court Ordered Treatment: Certification Form for Mental Health and Substance Use DisordersOpen a PDF
- Member Care Management Program Referral FormOpen a PDF
- Physician's Order for Personal Care Services (DOH-4359) Open a PDF
- SafetyNet Form for Inpatient Preauthorization Requests Open a PDF
- SafetyNet Form for Outpatient Preauthorization Requests Open a PDF
- UM Initial Determination Timeframes - Behavioral HealthOpen a PDF
Prescription Drugs
Univera Healthcare MyHealthSM, Child Health Plus and MyHealth PlusSM
- Inpatient Prior Authorization FormOpen a PDF
- Outpatient Prior Authorization FormOpen a PDF
- Adult Behavioral Health Home and Community Based Services Prior/Continuing Authorization FormOpen a PDF
- Behavioral Health Outpatient Treatment Request FormOpen a PDF
- Inpatient and Outpatient Neuropsychological and Psychological Testing Authorization FormOpen a PDF
Use the Open Negotiation Notice form for Surprise Bill claims with a service date Jan-01-2022 and after, to negotiate claims priced at Qualified Payment Amount.
- Open Negotiation Notice formOpen a pdf
All required details must be provided. Email the completed form to surprisebillnegotiationunivera@univerahealthcare.com
Additional Information
Federal No Surprise Bill
New York Surprise Bill
Questions
Federal Employee Plan (FEP), call 1-800-584-6617
All others, call 1-866-265-5983
