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Plan Information and Forms
Dual Special Needs Plan (DSNP)
Prescription drug mail order Forms
Try home delivery from OptumRx.
Complete this form to give others access to your account. Choose someone you trust such as a spouse, family member, caregiver or friend to access or help you manage your health plan.
Premium payment forms and information
Forms for transfers and deductions.
Electronic Funds Transfer Form
Social Security / Railroad Retirement Board Deduction Form
Reimbursement forms
Forms to ask us to pay you back.
Prescription Drug Direct Member Reimbursement Form
Medical Reimbursement Form
Authorization forms and information
Authorization and Appointment Forms.
Authorization to Share Personal Info
Complete this form to give others access to your account. Choose someone you trust such as a spouse, family member, caregiver or friend to access or help you manage your health plan.
Appointment of Representative
Nombramiento de un Representante
Appointment of Representative (Editable PDF)
Medication authorization forms
Medication and Part D Coverage and Authorization Forms.
Medicare Part D Coverage Determination Request Form
Medication Prior Authorization Request Form
Prescription Redetermination Request Form
Prior Authorization for Prescribers
For use by doctors/providers. Your doctor can go online and request a coverage decision for you.
Other resources and plan information
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 (Resources in Spanish)
Recursos en Espanol.
Medicare y Usted
Enrollment information
To get a UnitedHealthcare Dual Special Needs plan enrollment form (PDF), go to UHCCP.com 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.
Disenrollment information
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:
- Disenrollment Form (Online) Medicare Advantage Plan Disenrollment - Fill out the form and submit the request online.
- Disenrollment Form (PDF) Medicare Advantage Plan Disenrollment - Print the PDF form. Fill it out in black/blue ink. Mail or Fax it using the directions on the form.
Learn More
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