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Member Forms

 

Browse commonly requested forms to find and download the one you need for various topics including claims, reimbursement, and more.

Designation of Representative/ Authorization Form

You can fill out this form to designate someone to receive your protected health information (PHI). It includes instructions on how to complete the authorization form.

Download Designation of Representative/Authorization Form

 

Claim Form

You can complete this form online and print it from your computer. You'll also find helpful information on how to file a claim.

Download Claim Form

 

Fitness Reimbursement Form

Receive reimbursement for up to $100* per family on your membership at a fitness club or other fitness activities such as yoga and Zumba classes, personal trainers, sports teams, and more. The reimbursement is paid once per plan year to the plan enrollee upon proof of membership and payment. Use our fitness reimbursement form to request your reimbursement. Check the instructions for details on the types of fitness activities that qualify under this benefit and how to complete the reimbursement form.

*Medicare Extension members are eligible for a fitness reimbursement of up to $100 per enrollee per plan year.

Download Fitness Reimbursement Form

 

Diabetes Prevention Program Reimbursement Form (for non-Medicare members only)

You can receive reimbursement up to $500 when you complete 20 or more sessions in an approved diabetes prevention program. Review the reimbursement form for details.

Download Diabetes Prevention Program Reimbursement Form

 

Other Health Insurance Form

If you have medical benefits under another health plan in addition to the UniCare State Indemnity Plan, you need to let us know by completing our Other Health Insurance form.

Not sure which plan you’re in? You’ll find your plan name on the front of your ID card, under your member ID number.

 

Bill Checker Form (for non-Medicare members only)

The goal of the Bill Checker program is to detect overpayments that are the result of billing errors that only you may recognize. UniCare encourages you to review all of your medical bills for accuracy, just as you might do with your utility bills. If you find a billing error and get a corrected bill from your doctor, you will share in any actual savings realized by UniCare.

Download the bill checker form

 

Other Materials Available by Mail

Visit our Request Printed Plan Materials page for a list of additional member materials that you can order via our website. We will mail them to you promptly.