cloud.provideremail.uhc.com
Open in
urlscan Pro
13.111.140.122
Public Scan
Submitted URL: https://click.provideremail.uhc.com/?qs=057d4415ff14caeeb09636a61983d3cf0699f130611092a029fc0ee571832f7dd8f6caae29667a55c2c61ffd58e5...
Effective URL: https://cloud.provideremail.uhc.com/providerpreferences?qs=c40f0406b6da16d937bd3e29d0e2e5aa1702c2ee830783a659b1091681c17383449639271...
Submission: On June 27 via api from US — Scanned from DE
Effective URL: https://cloud.provideremail.uhc.com/providerpreferences?qs=c40f0406b6da16d937bd3e29d0e2e5aa1702c2ee830783a659b1091681c17383449639271...
Submission: On June 27 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://cloud.provideremail.uhc.com/providerpreferences?qs=c40f0406b6da16d937bd3e29d0e2e5aa1702c2ee830783a659b1091681c1738344963927194ae3e3de8c5c708d92af2659979d7b61c3aee20cd216b0590d36f28a4872d089e47699b53165814e0b500aeaf803db454e93826ff3e1b085e6b9ed
<form
action="https://cloud.provideremail.uhc.com/providerpreferences?qs=c40f0406b6da16d937bd3e29d0e2e5aa1702c2ee830783a659b1091681c1738344963927194ae3e3de8c5c708d92af2659979d7b61c3aee20cd216b0590d36f28a4872d089e47699b53165814e0b500aeaf803db454e93826ff3e1b085e6b9ed"
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>
Manage Your Email Preferences
</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;"> Personalize your experience with relevant content. Stay up-to-date with healthcare
professional news. </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=""
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=""
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="" 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="" 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>
</td>
</tr>
<script>
window.onload = function() {
var src = document.getElementById("MASKEDTIN"),
dst = document.getElementById("TIN");
src.addEventListener('input', function() {
dst.value = src.value;
});
};
</script>
<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="hidden" pattern="[(0-9)(nN)(/)(aA)]+"
name="TIN" value="" required="">
<input style="border:1px solid #002677; width:290px; height:35px; font-size: 13.5px; border-radius:2px;" class="input-fields require" id="MASKEDTIN" type="text" pattern="[(0-9)(nN)(/)(aA)]+"
name="MASKEDTIN" 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: 8px;">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: 8px;">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="AL">American Samoa - AS</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="AL">District of Columbia - DC</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="HI">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;"> Role <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<select id="roles" class="require" name="Role" style="font-size:13.5px; padding:2px 0px 2px 0px; text-align:left; width:290px; height:35px; border:1px solid #002677;border-radius:2px;"
required="">
<option value="">Select One</option>
<option value="Practice Staff">Practice Staff</option>
<option value="Office Manager/Practice Administrator">Office Manager/Practice Administrator</option>
<option value="Billing Staff">Billing Staff</option>
<option value="Prior Authorization/Referral Staff">Prior Authorization/Referral Staff</option>
<option value="Credentialing/Contracting Staff">Credentialing/Contracting Staff</option>
<option value="Admission/Intake/Scheduling Staff">Admission/Intake/Scheduling Staff</option>
<option value="Clinicians">Clinicians</option>
<option value="Physician">Physician</option>
<option value="Advanced Practice Clinician">Advanced Practice Clinician (Nurse Practitioner, Physician Assistant, etc.)</option>
<option value="Registered Nurse">Registered Nurse</option>
<option value="Pharmacist">Pharmacist</option>
<option value="Dentist">Dentist</option>
<option value="Medical Assistant">Medical Assistant</option>
<option value="Other">Other</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>
</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;"> 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>
<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;"> Preferred Primary Specialty <sup class="req">*</sup>
</td>
</tr>
<tr>
<td class="drop pb-10" valign="middle" align="left">
<select id="roles" class="require" name="Specialty" style="font-size:13.5px; padding:2px 0px 2px 0px; text-align:left; width:290px; height:35px; border:1px solid #002677;border-radius:2px;"
required="">
<option value="">Select One</option>
<option value="Allergy">Allergy</option>
<option value="Behavioral Health – Psychiatrists">Behavioral Health – Psychiatrists</option>
<option value="Behavioral Health – Psychologists">Behavioral Health – Psychologists</option>
<option value="Behavioral Health – Other Professionals">Behavioral Health – Other Professionals</option>
<option value="Cardiology">Cardiology</option>
<option value="Chiropractic Medicine">Chiropractic Medicine</option>
<option value="Dermatology">Dermatology</option>
<option value="Endocrinology">Endocrinology</option>
<option value="Gastroenterology">Gastroenterology</option>
<option value="Genetics">Genetics</option>
<option value="Hematology">Hematology</option>
<option value="Hospital Based Specialists">Hospital Based Specialists</option>
<option value="Infectious Disease Medicine">Infectious Disease Medicine</option>
<option value="MidLevel Clinicians">MidLevel Clinicians</option>
<option value="Neonatology">Neonatology</option>
<option value="Nephrology">Nephrology</option>
<option value="Nursing">Nursing</option>
<option value="OB/GYN">OB/GYN</option>
<option value="Occupational/Physical Therapists">Occupational/Physical Therapists</option>
<option value="Oncology">Oncology</option>
<option value="Opthamology">Ophthalmology</option>
<option value="Orthopaedic Surgery">Orthopedic Surgery</option>
<option value="Other Specialists">Other Specialists</option>
<option value="Otorhinolaryngology">Otorhinolaryngology</option>
<option value="Pediatric Specialists">Pediatric Specialists</option>
<option value="Podiatry">Podiatry</option>
<option value="Preventive Medicine">Preventive Medicine</option>
<option value="Primary Care - Family Practice">Primary Care - Family Practice</option>
<option value="Primary Care - General Practice">Primary Care - General Practice</option>
<option value="Primary Care - Geriatrics">Primary Care - Geriatrics</option>
<option value="Primary Care - Internal Medicine">Primary Care - Internal Medicine</option>
<option value="Primary Care - Pediatrics">Primary Care - Pediatrics</option>
<option value="Psychiatrists">Psychiatrists</option>
<option value="Psychologists">Psychologists</option>
<option value="Pulmonary Medicine">Pulmonary Medicine</option>
<option value="Radiology">Radiology</option>
<option value="Rheumatology">Rheumatology</option>
<option value="Surgery - General">Surgery - General</option>
<option value="Surgery - Specialized">Surgery - Specialized</option>
<option value="Urgent Care">Urgent Care</option>
<option value="Urology">Urology</option>
<option value="Other">Other</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>
</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 colspan="2" valign="top" align="left" style="font-size: 12px;">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tbody>
<tr>
<td valign="top" align="left">
</td>
</tr>
<tr>
<td colspan="2" valign="top" align="left">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checkcontainer">
<tbody>
<tr>
<td width="26" align="left" valign="top">
</td>
<td align="left" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checktext">
<tbody>
<tr>
<td align="left" valign="top" style="font-size: 14px;padding: 5% 10% 2% 0;">
<strong>Select your interests</strong>
<br>Help us populate your emails with the content you want to see.
</td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checkcontainer">
<tbody>
<tr>
<td width="26" align="left" valign="top">
</td>
<td width="26" align="left" valign="top" style="padding: 7px 0 0 0;">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checkcheck">
<tbody>
<tr>
<td align="left" valign="top">
<input name="PRIOR_AUTH_SUB" type="checkbox" id="PRIOR_AUTH_SUB" class="checkbox">
</td>
</tr>
</tbody>
</table>
</td>
<td align="left" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checktext">
<tbody>
<tr>
<td align="left" valign="top"> Advanced Notification / Prior Authorization </td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td width="26" align="left" valign="top">
</td>
<td width="26" align="left" valign="top" style="padding: 7px 0 0 0;">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checkcheck">
<tbody>
<tr>
<td align="left" valign="top">
<input name="ClaimsInformation" type="checkbox" id="ClaimsInformation" class="checkbox">
</td>
</tr>
</tbody>
</table>
</td>
<td align="left" valign="top">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checktext">
<tbody>
<tr>
<td align="left" valign="top"> Claims Information </td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td width="26" align="left" valign="top">
</td>
<td width="26" align="left" valign="top" style="padding: 7px 0 0 0;">
<table width="100%" border="0" cellspacing="0" cellpadding="0" class="checkcheck">
<tbody>
<tr>
<td align="left" valign="top">
<input name="MedicalPolicyUpdates" type="checkbox" id="MedicalPolicyUpdates" class="checkbox">
</td>
</tr>
</tbody>
</table>
</td>
<td align="left" valign="top">
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