• Overview
• Medicare
• Private Pay
• Helpful Customer Links
• For Clinical Partners
• For Employers
• Request Service

Donate to UHC »

Volunteer at UHC »

Donate or Sponsor UHC Claude Pepper Awards »

Customer
Care Center

Request Service

Please fill in the form below to request service from United HomeCare®. A service professional will then contact you with service options.

• Please enter your name.
• Please enter your phone.
• Please enter relationship to the client.
• Please enter the client name.
• Please enter the client Date of Birth.
• Please enter address.
• Please enter city.
• Please enter state.
• Please enter zip code.
• Please enter email address.
• Please enter client phone number.
• Please select whether you have had service from UHC before.
• Please select whether you are the customer's primary caregiver.
• Please select whether the customer has Medicaid.
• Please select whether the customer has Medicare.
• Please enter a matching CAPTCHA key.

Your Information:

Your Name:*

Phone Number:*

Relationship to the Client:*

---

Client Full Name:*

Client Date of Birth:*

Address:*

 

City:*

State:*

Zip Code:*

Email Address:*

Contact Phone:*

Requested Needs:

Have you had service from UHC before?*
Yes No

Date(s) Required:

from to

Service Required:

How can we assist you?

Is the person filling out this form the Customer's primary caregiver?*
Yes No

If yes, please provide Your Name:

Does the Customer have Medicaid?*
Yes No

If yes, is it an HMO?   Yes No

Does the Customer have Medicare?*
Yes No

If yes, is it a Medicare Advantage Plan (HMO,PPO, etc)?
Yes No

* Required field.

Please enter the characters below to help us minimize spam.

change image