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Plan Information and Forms

Dual Special Needs Plan (DSNP)

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.

Forms for transfers and deductions.

Electronic Funds Transfer Form

Social Security / Railroad Retirement Board Deduction Form

Forms to ask us to pay you back.

Prescription Drug Direct Member Reimbursement Form

Medical Reimbursement Form

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

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.

Medicare Member Rights1

If you have Medicare, you have the right to be:

  • Treated with courtesy, dignity and respect at all times.
  • Protected from discrimination. Every company or agency that works with Medicare must obey the law. They can't treat you differently because of your race, color, national origin, disability, age, religion, or sex.

You have the right to have:

  • Your personal and health information kept private.
  • Access to doctors, specialists, and hospitals for medically necessary services.

You have the right to get:

  • Medicare-covered services in an emergency.
  • Information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
  • Information about your treatment choices in clear language that you can understand and participate in treatment decisions.
  • Medicare information and health care services in a language you understand.
  • Your Medicare information in an accessible format, like braille or large print.
  • Answers to your Medicare questions.
  • A decision about health care payment, coverage of items and services, or drug coverage.

When you or your provider files a claim, you’ll get a notice letting you know what will and won’t be covered. This notice may come from:

  • Medicare
  • Your Medicare Advantage Plan (Part C) or other Medicare health plan
  • Your Medicare drug plan for Medicare drug coverage (Part D)

If you disagree with the decision on your claim, you have the right to file an appeal. You may:

  • Request a review (appeal) of certain decisions about health care payment, coverage of items and services, or drug coverage.
  • File complaints (sometimes called “grievances"), including complaints about the quality of your care. You may decide to do this if you have concerns about the quality of care and other services you get from a Medicare provider.

Medicare customers have the responsibility:

  • To know and confirm your benefits before getting treatment.
  • To show your member ID card before getting services.
  • To protect your member ID card from being used by another person.
  • To verify that the Provider you get services from is part of the health plan network.
  • To keep scheduled appointments.
  • To pay any copayments/coinsurance at the time you get treatment.
  • To ask questions and understand the care you are getting.
  • To follow the advice of your Provider and be aware of the possible outcomes if you do not.
  • To tell us your opinions, concerns and complaints.
  • To give information when asked to the health plan and contracted Providers that would help improve your health status.
  • To use emergency room services only for an injury or illness that you might think may be a serious threat to your life or health.
  • To follow the treatment plan agreed upon by you and your Provider.
  • To give all the health plan staff respect and courtesy.
  • To tell us of any change in address.

If you have questions or concerns about your rights, please call UnitedHealthcare Customer Service at the phone number listed on your member ID card. If you need help with communication, such as help from a language interpreter, customer service can assist you.

The Medicare program has written a booklet called Your Medicare Rights and Protection. To get a free copy, call toll-free 1-800-MEDICARE (1-800-633-4227) or TTY (1-877-486-2048) 24 hours a day, 7 days a week. Or you can access the Medicare website, to order the booklet or print it from your computer., Your Rights

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.

You 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: