Student claim form 2026

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The document is a claim form for UnitedHealthcare StudentResources (UHCSR) that outlines the process for submitting claims for medical expenses. It includes sections for insured student information, patient details, sickness or injury information, and other insurance details. The form provides instructions on how to complete and submit the claim, including acceptable methods of submission and necessary documentation. Additionally, it contains fraud warning statements applicable in various states.

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Click ‘Get Form’ to open the student claim form in the editor.
Begin by filling out the 'Insured Student Information' section. Enter your SR ID#, last name, first name, middle initial, home phone number, date of birth, mailing address, and email address.
If the patient is different from the insured student, complete the 'Patient Information' section with similar details including their relationship to the student.
In the 'Sickness/Accident/Injury Information' section, specify what the treatment was for and provide details such as the date it occurred and type of accident or injury.
Complete any additional fields regarding other insurance information if applicable. Ensure you sign and date where indicated.
Review all entries for accuracy before submitting. You can save your progress and return later if needed.

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