Forms - Health Choice Utah

Request Type:

Priority

Reporting Department:

Member Information

Are you the provider, the member, a vendor or a UUHP Customer Service Representative?

I am the:

If you called us to file an appeal, a Customer Advocate can file a written appeal on your behalf, if you give verbal consent. I give my verbal consent for this request to be considered a written appeal. I agree this information is correct and complete to the best of my knowledge.

Yes
No

CRM number (for UUHP Representatives only):

Your Name, if not the Member:

Phone # of Form Submitter

Member Name:

Member ID Number:

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Member Zip Code:

Member Phone Number:

Provider Information

Provider NPI:

Name of Provider Involved:

Provider Street Address:

Provider City:

Provider State:

Provider Zip Code:

Provider Phone Number:

Provider Fax Number:

Provider Specialty:

Health Plan Product

Health Plan:

Complaint Information

Date(s) of service related to complaint:

Claim Number(s) if applicable:

Referral number if applicable:

The Reason(s) for the complaint (Please Be Specific and Include Details):

Email Confirmation

Confirmation Email:

Upload File

Select file #1:

You can fax the information to the Complaint Team at the fax # 801-587-9985.

You may mail the information to:
Complaint Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107