UnitedHealth Group International Claims Transmittal - Free Download
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International Claims Transmittal
International Claims TransmittalInternational Claims Transmittal
International Claims Transmittal
Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading
information may be guilty of a criminal act punishable under law and may be subject to civil penalties.
Member signature__________________________________________ Date:__________________________
Return this form with the original medical bill or claim form via mail or fax to:
UnitedHealth Group
International Claims
PO Box 740817
Atlanta, GA 30374
Please complete all sections of this transmittal form. Claims may be delayed if all sections of this form are not completed. However, this
does not guarantee that additional information will not be requested from you to process the claim. You will be advised in writing should
additional information be required.
Please complete a new & separate claim transmittal form for:
* Each patient * Each inpatient hospital stay * Each different healthcare provider * Each currency type
Section 1 – Member & Patient Information
Check one: ___ I am an Expatriate or retiree living abroad. ___ I am traveling internationally for pleasure.
____ I am traveling internationally for business, however, live in the U.S.
Group Name Group Policy #
Member Name Member id #
Patient Name Patient Relationship
Patient Date of Birth Member Phone #
Member’s Return
Correspondence Address
Street
Town/city
Area postal code
Region
Country
In which country did the treatment take place
What type of currency is the bill submitted in
What is the total amount of the claim in U.S.Dollars (opt)
Please check the type of service that was rendered:
Office visit
Inpatient hospital care
Inpatient surgery
Outpatient surgery
Emergency room visit
Lab or X-ray services
Prescription drugs covered under your UHC plan
Medical supplies
Other_______________________
Date of service(s):__________________________
A brief explanation of the purpose of your healthcare provider visit; including
services rendered and/or procedures performed:
Section 2 – Healthcare Provider Contact Information
Name of Healthcare Provider
Name of facility or hospital
Address Street Town/city
Area postal code Region
Country
Telephone number (including 2-digit
country code)
Check here if this is a
repeat submission
Continued on reverse side
