Health Forms

Forms Description Access Information

Enhanced Point of Service (POS) Option/Standard POS Option Claim Forms

Complete a form only if you utilize out-of-network providers (in-network providers typically submit claims directly to the carrier)

UnitedHealthcare:
www.myuhc.com
1-800-577-8539

Traditional Indemnity Option Claim Forms

Complete a form when you need to utilize medical benefits

UnitedHealthcare:
www.myuhc.com
1-800-577-8539

Health Maintenance Organization (HMO)/Medicare HMO Forms

Contact your HMO/Medicare HMO about coverage, procedures and any required forms

Contact information is available:

  • On the back of your ID card, if you are currently enrolled in an HMO/Medicare HMO;
  • By visiting the Your Benefits Resources (YBR) website at www.resources.hewitt.com/nokia; or
  • By calling the Nokia Benefits Resource Center at 1-888-232-4111.

Mental Health and Chemical Dependency Coverage Precertification Forms
(Traditional Indemnity, Enhanced POS and Standard POS participants)

Check with your carrier before receiving treatment to confirm whether you need to complete a precertification form

UnitedHealthcare Behavioral Health and Chemical Dependency:
www.liveandworkwell.com
Enhanced and Standard POS:
1-800-577-8539
Traditional Indemnity:
1-800-577-8567

Prescription Drug Program Claim Forms
(Traditional Indemnity, Enhanced POS, Standard POS and UnitedHealthcare Group Medicare Advantage [PPO] participants)

Required when you need to use a pharmacy outside of the Express Scripts network

Express Scripts:
Participants not eligible for Medicare:

www.express-scripts.com
1-800-336-5934

Medicare-eligible participants:
1-800-230-0512
TTY: 1-800-716-3231

Prescription Drug Program Mail-Order Service Forms
(Traditional Indemnity, Enhanced POS, Standard POS and UnitedHealthcare Group Medicare Advantage [PPO] participants)

Required to request up to a 90-day supply of medications through the mail

Express Scripts:
Participants not eligible for Medicare:
www.express-scripts.com
1-800-336-5934

Medicare-eligible participants:
1-800-230-0512
TTY: 1-800-716-3231

Aetna Dental Plan Claim Forms (Aetna Dental Plan participants)

Required only if you use a dentist outside of the Aetna network

Aetna:
www.aetna.com

  • 1-800-220-5470 (if you are enrolled in the Dental Preferred Provider Organization [PPO] option)
  • 1-800-220-5479 (if you are enrolled in the Dental Maintenance Organization [DMO®] option)