Statement of Representative Form - Russian (PDF) Statement of Representative Form - Hmong (PDF) Statement of Representative Form - Arabic (PDF) Prior Authorization Information - Vietnamese (PDF) Prior Authorization Information - Spanish (PDF) Prior Authorization Information - Somali (PDF) Prior Authorization Information - Russian (PDF) Prior Authorization Information - Hmong (PDF) Prior Authorization Information - Arabic (PDF) Member Release of Information Form - Vietnamese (PDF) Member Release of Information Form - Spanish (PDF) Member Release of Information Form - Somali (PDF) Member Release of Information Form - Russian (PDF) Member Release of Information Form - Hmong (PDF) Member Release of Information Form - Arabic (PDF) Prescription Drug Transition Policy (PDF) Rights and Responsibilities Upon Disenrollment (PDF) Instructions for Appointing a Representative (PDF) Part C Organizational Determinations, Appeals and Grievances Part D Coverage Determinations, Appeals and Grievances Sign up to have your plan premium automatically deducted from your checking or savings account each month. Request for Redetermination of Medicare Prescription Drug Denial Form (PDF)ĭeceased Member: Affidavit for the Collection of Personal Property () Request for Medicare Prescription Drug Coverage Determination Form (PDF) Use this form to be reimbursed for covered health care expenses.
Prior Authorization Information (PDF) Member Forms TruHearing Hearing Aid Benefit Information To request a bound copy of our Provider/Pharmacy Directory, please call customer service at the number on the back of your member ID card.Ģ022 Classic Choice Dental Overview (PDF) We are available 24 hours a day, seven days a week. If you are a member and have questions about your particular Group plan, please call UCare Medicare Group Customer Service at 61 or 1-87 toll free. Note: Summary of Benefits and Evidence of Coverage are determined per group.
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