WHAT CAN WE HELP YOU WITH?

Información en Español

Popular Links

Testimonials

The program has helped me to survive and cope with my severe depressions and to help me cope with everyday problems that come with the depression. It gives me a better quality of life.
Denise D., Client, on the impact of Healthy IDEAS
READ MORE TESTIMONIALS »

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.

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.