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• Personal Representative Appointment Form  Â
• Specific Case Authorization Form Â
• Medical Claim Form
• Claim Information Form
• Pharmacy Claim Information Form
• Privacy Notice Â
• UnitedHealth Allies Discount Services

Personal Representative Appointment Form (PRA)/Yearly Authorization Form

If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.

Specific Case Authorization Form

If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.

Medical Claim Form

This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:

• Clip, do not staple, all bills to the completed form.
• Make sure all bills or itemized receipts indicate a diagnosis code, procedure code, date of service, cost, and the provider’s tax ID number.
• Mail claim to: UnitedHealthcare StudentResources P. O. Box 809025 Dallas, TX 75380
• OR Fax claim to: 469-229-5625

Claim Information Form

Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.

Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025

Or fax to:Â
469-229-5625

Pharmacy Claim Form

This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:

OptumRx Claims Department

P.O. Box 29044

Hot Springs, AR 71903

Privacy Notice

This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.

UnitedHealth Allies Discount Services

This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.