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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 address.
• Please enter your city.
• Please enter your state.
• Please enter your zip code.
• Please enter your email address.
• Please enter your 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:*

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:

Other Info:

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.

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