cloud.provideremail.uhc.com
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13.111.140.122
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Submitted URL: https://click.provideremail.uhc.com/?qs=d0a862515a5ee63b53dbcc781fb1622061a1267db24a54764ae05da043dd16a6f244b5ffa7db787c4f07de4ed80f...
Effective URL: https://cloud.provideremail.uhc.com/updatedetails?qs=0e8c1d579046a06017af31530b88f430bee2764257d2d6d2a8eb91c3d63868d57f043bab4987d23...
Submission: On November 03 via api from US — Scanned from DE
Effective URL: https://cloud.provideremail.uhc.com/updatedetails?qs=0e8c1d579046a06017af31530b88f430bee2764257d2d6d2a8eb91c3d63868d57f043bab4987d23...
Submission: On November 03 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://cloud.provideremail.uhc.com/updatedetails?qs=0e8c1d579046a06017af31530b88f430bee2764257d2d6d2a8eb91c3d63868d57f043bab4987d23938e16981f1ad745a618cf0aaaf1ea724098d8cbf33e4568a031fa91c0cec5763309c1d46e2caaf82dffc82aa338a0da3
<form action="https://cloud.provideremail.uhc.com/updatedetails?qs=0e8c1d579046a06017af31530b88f430bee2764257d2d6d2a8eb91c3d63868d57f043bab4987d23938e16981f1ad745a618cf0aaaf1ea724098d8cbf33e4568a031fa91c0cec5763309c1d46e2caaf82dffc82aa338a0da3"
method="post" class="needs-validation" validate="">
<!--Background color table-->
<table width="100%" border="0" cellpadding="0" cellspacing="0" align="center" style="margin:0; padding:0;">
<tbody>
<tr>
<td>
<div align="center">
<table border="0" cellpadding="0" cellspacing="0" align="center" id="mainbody" style="width:900px;">
<tbody>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse;">
<!-- spacer row -->
<tbody>
<tr>
<td>
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
<!-- End spacer row -->
<!-- UHC Lo row -->
<tr>
<td>
<table border="0" cellspacing="0" cellpadding="0" align="left" id="unitedhealthlogo">
<tbody>
<tr>
<td valign="top" align="left">
<img src="https://image.provideremail.uhc.com/lib/fe3f11727564047d741c70/m/1/UHC_MB_Lockup_blu_RGB200x62.png" alt="UnitedHealthcare">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<!-- spacer row -->
<tr>
<td>
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
<!-- End spacer row -->
<tr>
<td>
<table width="100%" bgcolor="#003DA1" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td align="left" valign="top" bgcolor="#E5F8FB">
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
<table>
<tbody>
<tr>
<td style="font-size:18px; color: #002677; font-family:Georgia,serif; padding: 0px 0px 6px 20px;">
<b>
My contact information
</b>
<br>
</td>
</tr>
</tbody>
</table>
<table>
<tbody>
<tr>
<td style="font-size:14px; color: rgb(68, 68, 68); font-family:Arial,Helvetica,sans-serif; padding: 0px 0px 6px 20px;"> Need to make changes? Enter your updates to ensure you don’t miss a Network News email.
</td>
</tr>
</tbody>
</table>
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<!-- end UHC logo -->
</td>
</tr>
<tr>
<td>
<!-- body -->
<table width="100%" border="0" cellspacing="0" cellpadding="0" align="left" id="bodycol">
<tbody>
<tr>
<td valign="top" align="left">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td valign="top" align="left" style="padding: 14px;">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td valign="top" align="left">
<div class="required-fields">
</div>
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> First Name <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="form-control" pattern="[^|]+" type="text" name="First_Name" value="Julie"
required="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> Last Name <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" pattern="[^|]+" type="text" name="LastName"
value="Mccausland" required="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="hide-this" colspan="2">
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
<tr>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> Email <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" id="email" type="email" pattern="[^|]+"
name="EmailAddress" value="mccauslandj2@upmc.edu" required="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
</td>
</tr>
</tbody>
</table>
</td>
<script type="text/javascript">
function confirmEmail() {
var email = document.getElementById("email").value
var confemail = document.getElementById("confemail").value
if (email != confemail) {
alert('Email Not Matching!');
}
}
</script>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> Confirm Email <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" id="confemail" pattern="[^|]+" onblur="confirmEmail()"
type="email" name="" value="mccauslandj2@upmc.edu" required="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="hide-this" colspan="2">
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
<tr>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> TIN (tax ID number) <sup class="req">*</sup>
<em style="font-size: 10px;">See format requirement below</em>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" id="TIN" type="text" pattern="n/a|[0-9,]+" name="TIN"
value="*****" placeholder="123456789,987654321" required="" multiple="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
<br>
<em style="font-size: 10px;">type n/a if you are not a care provider</em>
</td>
</tr>
</tbody>
</table>
</td>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> NPI Number <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" pattern="[^|]+" type="text" name="NPI" value=""
required="">
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
<br>
<em style="font-size: 10px;">type n/a if you are not a care provider</em>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td class="hide-this" colspan="2">
<img alt="" src="https://image.unitedhealthcare-hmhb.com/lib/fe631570726c05787512/m/2/spacer.gif" width="1" height="20" border="0" style="display: block;">
</td>
</tr>
<tr>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> State <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<select id="state" class="require" required="" name="State"
style="font-size:13.5px; padding:2px 0px 2px 0px; text-align:left; width:290px; height:35px; border:1px solid #002677;border-radius:2px;">
<option value="" selected="" disabled="" hidden="">Select One</option>
<option value="AL">Alabama - AL</option>
<option value="AK">Alaska - AK</option>
<option value="AZ">Arizona - AZ</option>
<option value="AR">Arkansas - AR</option>
<option value="CA">California - CA</option>
<option value="CO">Colorado - CO</option>
<option value="CT">Connecticut - CT</option>
<option value="DE">Delaware - DE</option>
<option value="FL">Florida - FL</option>
<option value="GA">Georgia - GA</option>
<option value="HI">Hawaii - HI</option>
<option value="ID">Idaho - ID</option>
<option value="IL">Illinois - IL</option>
<option value="IN">Indiana - IN</option>
<option value="IA">Iowa - IA</option>
<option value="KS">Kansas - KS</option>
<option value="KY">Kentucky - KY</option>
<option value="LA">Louisiana - LA</option>
<option value="ME">Maine - ME</option>
<option value="MD">Maryland - MD</option>
<option value="MA">Massachusetts - MA</option>
<option value="MI">Michigan - MI</option>
<option value="MN">Minnesota - MN</option>
<option value="MS">Mississippi - MS</option>
<option value="MO">Missouri - MO</option>
<option value="MT">Montana - MT</option>
<option value="NE">Nebraska - NE</option>
<option value="NV">Nevada - NV</option>
<option value="NH">New Hampshire - NH</option>
<option value="NJ">New Jersey - NJ</option>
<option value="NM">New Mexico - NM</option>
<option value="NY">New York - NY</option>
<option value="NC">North Carolina - NC</option>
<option value="ND">North Dakota - ND</option>
<option value="OH">Ohio - OH</option>
<option value="OK">Oklahoma - OK</option>
<option value="OR">Oregon - OR</option>
<option value="PA">Pennsylvania - PA</option>
<option value="PR">Puerto Rico - PR</option>
<option value="RI">Rhode Island - RI</option>
<option value="SC">South Carolina - SC</option>
<option value="SD">South Dakota - SD</option>
<option value="TN">Tennessee - TN</option>
<option value="TX">Texas - TX</option>
<option value="UT">Utah - UT</option>
<option value="VT">Vermont - VT</option>
<option value="VA">Virginia - VA</option>
<option value="VI">Virgin Islands - VI</option>
<option value="WA">Washington - WA</option>
<option value="WV">West Virginia - WV</option>
<option value="WI">Wisconsin - WI</option>
<option value="WY">Wyoming - WY</option>
</select>
<div class="invalid-feedback" style="color: #cf0000; font-size: 14px; font-weight: 500;">Please fill out this field. </div>
</td>
</tr>
</tbody>
</table>
</td>
<td class="drop" valign="top" align="left">
<table width="290px" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td class="drop form-label" width="25%" valign="middle" align="left" style="color: #333333; font-size: 14px; font-weight: 600;"> Organization Name </td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields" pattern="[^|]+" type="text" name="OrganizationName" value="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
<td valign="top" align="left">
</td>
</tr>
<tr>
<td align="center" style="vertical-align:top; padding:17px 0px 9px 0px">
<table border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td align="left">
<button style=" font-size: 16px; border-radius:20px; background-color:#002677; color:#FFFFFF; padding:10px 25px; border:solid 0px #FFFFFF; cursor:pointer; font-weight: 600;" type="submit" id="the_button"
name="submitted" width="151" border="0" value="submitted">Submit</button>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<!-- END body -->
</td>
</tr>
<tr>
<td align="left" style="font-family:Arial; font-size:12px; line-height:18px; padding:20px 0px 15px 20px; color:#757588;"> Fields marked with an asterisk * are required <br>
<br>
<b>Tax ID # must be submitted as only 9 digits with no additional characters or spaces. If more than one Tax ID # is applicable, please submit each 9-digit tax ID # separated by a comma with no additional spaces or characters. For example: 123456789,02345678
</b>
<br>
<br> To the extent information conveyed via Network News conflicts with applicable state law, UnitedHealthcare will follow such applicable state law. <br>
<br> Please note that on occasion, you may also receive other relevant emails from us based on your profile. If your intent is to
<a href="https://cloud.provideremail.uhc.com/TEST_Unsubscribe_Page?qs=0e8c1d579046a06017af31530b88f430bee2764257d2d6d2a8eb91c3d63868d57f043bab4987d239dca9ed44fbd94a4d918d7024c6f958b2b085286f20f1ade34a8f7701884298f4">opt-out</a>
from all non-regulatory email communication from UnitedHealthcare please be sure to select " I no longer do business with UnitedHealthcare. Please remove me from all UnitedHealthcare emails including Network News and other notices
<br>
<br>
</td>
</tr>
</tbody>
</table>
</div>
</td>
</tr>
</tbody>
</table>
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<script>
function replaceValidationUI(form) {
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var submitButton = form.querySelector("button:not([type=button]), input[type=submit]");
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</form>Text Content
Thank you. Your preferences have been successfully saved. × My contact information Need to make changes? Enter your updates to ensure you don’t miss a Network News email. First Name * Please fill out this field. Last Name * Please fill out this field. Email * Please fill out this field. Confirm Email * Please fill out this field. TIN (tax ID number) * See format requirement below Please fill out this field. type n/a if you are not a care provider NPI Number * Please fill out this field. type n/a if you are not a care provider State * Select One Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Puerto Rico - PR Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Virgin Islands - VI Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY Please fill out this field. Organization Name Submit Fields marked with an asterisk * are required Tax ID # must be submitted as only 9 digits with no additional characters or spaces. If more than one Tax ID # is applicable, please submit each 9-digit tax ID # separated by a comma with no additional spaces or characters. For example: 123456789,02345678 To the extent information conveyed via Network News conflicts with applicable state law, UnitedHealthcare will follow such applicable state law. Please note that on occasion, you may also receive other relevant emails from us based on your profile. If your intent is to opt-out from all non-regulatory email communication from UnitedHealthcare please be sure to select " I no longer do business with UnitedHealthcare. Please remove me from all UnitedHealthcare emails including Network News and other notices