Provider Forms and Documents

Standardized Prior Authorization Form

This form was developed by the Massachusetts Health Care Administrative Simplification Collaborative in May 2012. You can use the prior authorization form to submit a prior authorization request to UniCare for review, but you will still need to submit the appropriate UniCare precertification worksheet to provide the necessary clinical documentation to support the request. (UniCare does not require providers to submit the standardized prior authorization form - only the appropriate UniCare precertification worksheet.)

Download Standardized Prior Authorization Form

Outbound Fax Information Form for
Utilization Management (UM) Decision Letters

Use this form to begin receiving UniCare utilization management decision letters for approvals, denials, and requests for information by fax.

Download Outbound Fax Information Form for UM Decision Letters

HealthCare Administrative Solutions (HCAS) Provider Enrollment Form

Use this form to enroll as a UniCare contracted provider. Please complete a separate page for all new providers in the group.

Download HCAS Provider Enrollment Form

Standardized Provider Information
Change Form

If you're an existing UniCare contracted provider, use this form to let us know about changes to your practice, such as the names of new providers in your group.

Download Standardized Provider Information Change Form

Member ID Cards

View samples of the member ID cards for all four plans. UniCare ID cards show copay amounts and other plan information.

• Basic
• PLUS
• Community Choice
• Medicare Extension