Request Form For Provider On-Call And After Hours Coverage Information

Request for Provider On-Call and After Hours Coverage Information

Please provide UnitedHealthcare Community Plan with the requested information regarding providers

offering on-call and after hours coverage to your patients when you are not available. You are required to

provide on-call and after hours coverage to remain in compliance with your UnitedHealthCare

Community Plan agreement. Please send this information to us within 30 days of receipt of this form as

claim payments may be affected.

Action Required:

Please provide the following information and return to us using one of the following methods:

1) Fax this form to: 844-872-1877 Attn: Provider Relations

2) Email:

3) Mail: 1311 West President George Bush Highway, Richardson, TX 75080

Email or fax are preferred methods for the most timely updates to your call coverage information. If you

have questions, contact your Provider Relations representative or call Provider Services at 800-690-1606.

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Please provide the following information for ALL practices providing on-call and after hours

coverage for your practice. On-call and after hours coverage must be offered byUnitedHealthcare

Community Plan participating providers. Please submit this form within 30 days of a change in

your provider on-call and after hours coverage.

Your Name (please print): __________________________________________________________

Your Practice Name: __________________________________________________________________

Your Practice Tax ID: _________________________________________________________________

Your Telephone Number with Area Code: ______________________________________________

Call Coverage Provider(s) Name: ________________________________________________________

Call Coverage Practice Name(s): _________________________________________________________

Call Coverage Practice Tax ID(s): ________________________________________________________

Call Coverage Practice Telephone Number: _______________________________________________

Effective Date of Coverage Relationship: _________________________________________________

Termination Date of Coverage Relationship: _______________________________________________

Call Coverage Provider(s) Name: ________________________________________________________

Call Coverage Practice Name(s): _________________________________________________________

Call Coverage Practice Tax Id(s): ________________________________________________________

Call Coverage Practice Telephone Number: _______________________________________________

Effective Date of Coverage Relationship: _________________________________________________

Termination Date of Coverage Relationship: _______________________________________________

Call Coverage Provider(s) Name: ________________________________________________________

Call Coverage Practice Name(s): ________________________________________________________

Call Coverage Practice Tax ID(s): ________________________________________________________

Call Coverage Practice Telephone Number: _______________________________________________

Effective Date of Coverage Relationship: _________________________________________________

Termination Date of Coverage Relationship: _______________________________________________

Provider (or Designee) Signature: _____________________________ Date: _____________________

Doc#: PCA17508_20150804

Request Form For Provider On-Call And After Hours Coverage Information - Uhc