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Page 1 of 72022 Enrollment Request Form o UnitedHealthcare Dual Complete (HMO DSP) H1375001000 UD2Information about you. (Please type or print in black or blue ink) Last NameFirst Name Sex Male FemaleBirth
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It is a program for providers to submit necessary forms and references.
Providers who work with UnitedHealthcare are required to file these forms.
Providers can fill out the forms online through the www.uhcprovider.com website.
The purpose is to ensure that providers have submitted all required information and forms.
Providers must report their basic information, credentials, and any necessary references.
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