United HealthCare Medical Claim

This form should be completed when you have paid for services and need to request reimbursement. When seeking care in the U.S., providers will generally submit your claims directly to UnitedHealthcare eliminating the need for you to do so. Requests for reimbursement should be faxed or mailed to the address(es) shown on the form.

  United HealthCare International Claim Form

This form should be completed if you have had emergency medical care rendered while travelling outside the U.S. and you are covered under one of the plan options administered by United Healthcare

  United Healthcare Vision Claim Form for Non-Network Provider

This form needs to be completed only if you use a provider who does not participate in the UnitedHealthcare Vision network. Network providers will file the claim for you.

  MetLife Dental Claim Form

  Prescription Drug Mail Order Form

Use this form to mail in a prescription your doctor has already written.

  Prescription Drug Reimbursement Form

This form should be completed if you need to submit expenses for medications you purchased at a non-network retail pharmacy.

  Dependent Care FSA Claim Form

Use this form if you are currently enrolled in the Dependent Day Care FSA to submit claims for reimbursement of eligible expenses. Please be sure to attach the necessary documentation.  

  Health Care FSA Claim Form

Use this form if you are currently enrolled in the Health Care FSA to submit claims for reimbursement of eligible expenses. Please be sure to attach the necessary documentation.