Forms

Do you have an interest in partnering with United Concordia or is there a status change in your office? If so, click on the appropriate link below.

• Become a United Concordia Provider
• Add/Delete Dentist from a Dental Office
• Obtain a Provider Number
• Request for Group Account Form

Claim Forms

• Standard Claim Form
• Formulario de reclamos convencional
  
  
• Standard Claim Form (Arizona only)
• Formulario de reclamos convencional (Solo Arizona)
  
  
• Standard Claim Form (New York only)
  
  
• Mutual of Omaha Standard Claim Form
  
  
• Mutual of Omaha Standard Claim Form (Arizona only)
  
  
• Mutual of Omaha Claim Form (New York only)
  
  

Referral Forms

• Specialty Referral Claim Form
  
  
• Specialty Referral Claim Form (Arizona only)
  
  
• Specialty Referral Claim Form (California only)
  
  
• Uniform Dental Consultation Referral Form (Maryland only)