Authorization for Release of Information - UnitedHealthcare Inc 2026

The document is a Member Enrollment/Change Request Form for large employers in New Jersey, provided by Oxford Health Insurance, Inc. It outlines the process for employers and employees to enroll or make changes to health insurance coverage, including adding or removing subscribers and dependents, as well as options for coverage continuation under COBRA or NJSGC. The form requires detailed information about the group, employee, and dependents, along with necessary signatures and authorizations.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Group Information section. Enter the Group Name, Group Number, and Plan ID clearly.
In the Enrollment section, indicate whether you are adding or removing a subscriber or dependent. Fill in the relevant dates and names as required.
For coverage continuation, check all applicable boxes and provide necessary dates and qualifying event numbers.
Complete the Employee Information section with your personal details including name, SSN, birthdate, and contact information.
If applicable, provide additional information for dependents in Section D and ensure all required signatures are included at the end of the form.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (140 Votes)
2019	4.4 Satisfied (135 Votes)
2011	4 Satisfied (24 Votes)

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How do I get prior authorization for UnitedHealthcare?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.