United Health Administrators

Provider Assistance Form

Employer Information

Employer does not exists.
Please enter member id..
If you have your Member ID, found on your card, please enter it here and click Load My Information to automatically update the form with your family info.

Employee Information

Please enter first name.
Please enter last name.
Please Enter Date of Birth.
Phone number must be 10 digits.
Please Enter Correct Email.
Please select best contact method.
Please enter employee ID.
Please select Effective date.
Please enter valid last 4 digits of SSN.

Plan Data

Phone number must be 10 digits.
Please select benefit year.
Please enter valid deductible number.
Please enter valid deductible used to date.
Please enter valid OOP MAX.
Please enter valid OOP MAX used to date.
Please enter coinsurance plan pay.
Please enter relevant CoPay.
Please enter visit limit or other details.
Please enter PreAuth requirement's.
Please select end goal option.

Family Members

DEPENDENT {{index + 1}}:
Please enter first name.
Please enter last name.
Please Enter Date of Birth.
Please select relationship type.

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Physician Information

PHYSICIAN {{index + 1}}:
Please enter physician first name.
Please enter physician last name.
Please select title.
Phone number must be 10 digits.
Please select speciality.
Please enter a valid ZIP code.
Please select network level.
Please select patient.
    Please select.

Please select year and month.

Please confirm scheduled appointment.
Please enter a valid date.
Please select next schedule.


3rd Party Information

Please enter 3rd party name.
Please Enter Correct Email.
Please select priority level.
Please enter comment.
    Please select.

PHYSICIAN {{index + 1}}:
Thank you for submitting your provider nomination form.
The following provider(s) is in the PHCS Practitioner Only Network:
{{providerNameRecord.name}}

You are all set!. Please mention the PHCS logo on your ID Card when scheduling an appointment.

The following provider(s) does not participate with PHCS:
{{providerNameRecord.name}}

Our Provider Relationships team will reach out to the provider on your behalf.

Please be advised that provider nomination requests are processed based on urgency.

If you need to make an appointment with a provider and we have not already reached out to you regarding the provider’s status, please call our Customer Service number and we will help you to schedule your appointment.

PHYSICIAN {{index + 1}}:
Thank you for submitting your provider nomination form.
{{providerNameRecord.firstname}} {{providerNameRecord.lastname}}

Our Provider Relationships team will reach out to the provider on your behalf.

Please be advised that provider nomination requests are processed based on urgency.

If you need to make an appointment with a provider and we have not already reached out to you regarding the provider’s status, please call our Customer Service number and we will help you to schedule your appointment.