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.

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