UnitedHealth PremiumĀ® Physician Designation Program Notification Form

Please provide as much information as you can about your notification from UnitedHealthcare regarding your Premium designation. If needed, you can fill out the form multiple times.  


Contact Information


UnitedHealthcare Plan Information

(e.g., OneNet PPO, Oxford Health Plans, United HealthcareOne, UnitedHealthcare Medicare Advantage)
(e.g., Ophthalmologist or Ophthalmologist; Retina Surgery)

PremiumĀ® Physician Designation Program Information

First, MI, Last
mm/dd/yyyy

Please include any change to your designation
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