Instructions For UHC Carriers Follow These 3 Easy Steps Call United Healthcare at(800) 557-5745Either the subscriber or the dependent can make this call to United Healthcare. Once connected,tell the rep. exactly this…“I am giving permission for Peaks Recovery Centers to verify out of network benefits for __________ (name of the person in need of treatment). Write down repsname and reference #Make sure to take note of these two things, therefore you can easily enter this information into the form below.. You’re Almost There!Please fill out the form below, adding in the information you just collected from phone call with United. Verify Insurance - UHC Form to verify United Health Care Insurance Contact InformationWho should we contact after verification?Name* First Last Phone*Email* Insurance InformationInsurance Representative's Name*Reference #*Primary's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient's Name* First Last Primary Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Date Of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance Provider*Please SelectUnited Health CareUMROtherMember ID*Group ID Number*Insurance Phone NumberCommentsFront Of Insurance Card*Back Of Insurance Card*By submitting this form, I agree to be contacted by Peaks Recovery Centers. Our admissions director will contact you shortly to discuss your recovery options. All information shared with us is completely confidential. See our HIPAA Privacy Policy.