515-8746 Emergency Action Plan - NO NurseLine - FINAL

Emergency Action Plan

Plan ahead for unexpected health problems. Start by completing your Personal Health Record on myUHC.com. When
your primary care physician is unavailable, this form will help you create a plan that allows you and your family to get
the care you need. Keep it posted where everyone in your home can readily see it.

Type of care What they do My choice for care

Primary Care Treatment for most non-life-threatening conditions Physician
Physician including treatment for conditions listed in the Retail Clinic
Clinic and Urgent Care sections listed below Address

` Physician Office visit: $111 Phone
Hours
Convenience Treatment for: Clinic
Care Clinic ` Common infections (e.g., strep throat) Address
Walk-in clinics ` Minor skin conditions (e.g., poison ivy)
located in retail ` Flu shots Phone
stores, supermarkets ` Physicals Hours
or pharmacies ` Minor cuts
` Earaches Urgent Care
Urgent Care Center ` Convenience Care Clinic visit: $78 Address

Emergency Room Treatment for: Phone
911 ` Strains, sprains Hours
` Minor broken bones (e.g., finger)
` Minor infections Hospital
` Minor burns Address
` X-rays
` Urgent Care Center visit: $152 Phone

Serious emergencies such as:

` Heavy bleeding ` Major burns

` Large open wounds ` Spinal injuries

` Sudden change in ` Severe head injury
vision ` Difficulty breathing
` Major broken bones
` Chest pain ` Emergency Room

` Sudden weakness or visit: $1,351
trouble talking

This is a sample list of services and may not be all-inclusive. © 2012 United HealthCare Services, Inc.
UHCEX550361-000
Cost information represents averages only based on internal claims data and is not tied to a specific condition
or treatment. Your out-of-pocket costs will vary based on plan design.

Not all treatment facilities are covered equally under all plan designs. Refer to the plan design for complete
details. Some treatments may require pre-authorization or a referral from your Primary care physician.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
Administrative services provided by United HealthCare Services, Inc. or their affiliates.

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