TPMO Subcontracted Relationship Submitting Form

CMS Regulation Third Party Marketing Organization Subcontracted Relationships

Third-Party Marketing Organizations (TPMO) are required to disclose to UnitedHealthcare all subcontracted relationships used for marketing, lead generation, and enrollment. Complete and submit a form for each subcontractor used for marketing, lead generation, and/or enrollment activities. When a subcontracted relationship ends, complete a new form that reflects an updated Contract End Date. Contact Sales_Oversight@uhc.com if you have questions related to filling out this form.

* Required

User Information Requested :

1. Submitter's Name (First/Last) *

Please enter submitter's name (first/last)

2. Submitter's Organization *

Please enter submitter's organization

3. Submitter's Email Address *

Please enter a valid email address

4. Submitter's Phone Number *

Please enter submitter's phone number

Please enter a valid phone number

5. Date Entered *

Subcontracted Entity Information Requested :

1. Subcontracted Organization's Name *

Please enter subcontracted organization's name

2. Contract Start Date *

3. Contract End Data (if applicable)

Please enter valid contract end date

4. TPMO function(s) performed by subcontracted organization (select all that apply) *

Enrollment Lead Generation Marketing/Advertising

5. Does this subcontractor have an offshore location outside the United States that will be supporting this activity? *

Yes No

6. Details related to offshore location and function(s) *

Please enter the details related to offshore location and function(s)

Error occurred while submitting the form, please enter valid input.

Need Help?

Contact the Producer Help Desk (PHD)

View Hours

Monday – Friday 7am – 9pm CST

PHD Chat English 888-381-8581 Español Presione la opción 2 phd@uhc.com

You don't have access to this page

Login As :

Need more time?