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Plan Information and Forms

Dual Special Needs Plan (DSNP)

Forms for transfers and deductions.

Electronic Funds Transfer Form

Premium Deduction Form

Forms to ask us to pay you back.

Drug Reimbursement Form

Medical Reimbursement Form

Authorization and Appointment Forms.

Authorization to Share Personal Info

Appointment of Representative

Nombramiento de un Representante

Appointment of Representative (Editable PDF)

Medication and Part D Coverage and Authorization Forms.

Medicare Part D Coverage Determination Request Form

Medication Prior Authorization Request Form

Prescription Redetermination Request Form

Additional resources for you to download.

UHC Commitment to Quality

Medicare Appeals and Grievances Form

Medicare Supplement Termination Letter

Potential Contract Termination

Complete this letter when a member is terminating their Medicare supplement plan (Medigap) and replacing it with a UnitedHealthcare Medicare Advantage plan.

Recursos en Espanol.

Medicare y Usted

To get a UnitedHealthcare Dual Special Needs plan enrollment form (PDF), go to and enter your ZIP code and click the "Find Plans" button. When you find the plan you may want to enroll in, click the "View Plan Details" button to access your enrollment form.

UnitedHealthcare health plans are offered by United Healthcare Insurance Company. We (and other private insurance companies) work with federal and state agencies to provide government-sponsored health insurance. We are not part of Medicare. We work with the Centers for Medicare & Medicaid Services (CMS) and many state governments to provide health coverage for Medicare and Medicaid recipients.

Medicare Special Needs Plan Disenrollment Form

Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Medicare Prescription Drug Plan Disenrollment

Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.

Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you:

  • Move your permanent residence out of the plan's service area (including incarceration).
  • Lose your entitlement to Medicare benefits under Part A and/or are no longer enrolled in Part B.
  • Fail to pay the monthly premium (if your plan has one) after your plan has made reasonable efforts to collect the unpaid premium.
  • Become deceased.
  • Knowingly misrepresent that you expect to receive reimbursement for covered Medicare prescription drug plan drugs through other third-party coverage.
  • Enroll in a different prescription drug plan. You will automatically be disenrolled from your previous plan (if it has prescription drug coverage).
  • Fail to pay your Part D-IRMAA to the government and CMS notifies the plan to effectuate the disenrollment.

ou may also be disenrolled for "disruptive behavior." Disruptive behavior is defined as behavior that substantially impairs UnitedHealthcare's ability to arrange or provide care for you or other plan members. Other Medicare prescription drug plan sponsors may decline your enrollment if you have been disenrolled for disruptive behavior. 


In all cases of disenrollment, your plan is required to provide proper notice to you and give you the opportunity to appeal the decision prior to disenrollment.

You can request disenrollment from your Medicare Advantage (Part C) plan, your Medicare Special Needs plan (SNP) or Medicare prescription drug (Part D) plan and switch to Original Medicare (Parts A and B) online or by mail/fax: