UnitedHealth Premium® Physician Designation Program Notification Form - The American Society of Retina Specialists

Contact Information

Practice name

City, State, ZIP*

Email address

Phone number

Can we contact you directly if more information is needed?

Plan name

(e.g., OneNet PPO, Oxford Health Plans, United HealthcareOne, UnitedHealthcare Medicare Advantage)

City/State

Type of plan*

Number of patients enrolled in plan(s)

What is your UnitedHealthcare provider designation?

(e.g., Ophthalmologist or Ophthalmologist; Retina Surgery)

Where you aware of your assignment into the Premium Physician Designation Program

Name of physician receiving Premium Designation letter

First, MI, Last

Total number of physicians in practice under Premium Designation Program

Date Premium Designation letter received

mm/dd/yyyy

Practice name

Address where Premium Designation letter received

Do you have other office locations where a Premium Designation letter was not received?

If yes, please provide the address of the other office location(s) and details of the assessment result

What was the outcome of your Assessment Result?

Have you attempted a reconsideration?

If you submitted a reconsideration and received a response, please provide information on the response

Please include any change to your designation

How many days were you given to request a reconsideration?

Have you received unofficial communications from the plan directing you toward a specific treatment option?

If you answered yes, please describe the interaction

Please provide any other information that you think might be helpful

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