Chronic Condition Pre-Assessment Form

Download If you are enrolling in UHC Preferred Complete Care FL-0003 (HMO C-SNP), you must fill out the this form.

UHC Preferred Medicare Advantage FL-002P (HMO)

Enrollment Application

Application Instructions

Before you enroll

UHC Preferred Dual Complete FL-D01P (HMO D-SNP)

Enrollment Application

Application Instructions

Before you enroll

Need Assistance Completing This Form?

UHC Preferred Medicare Advantage FL-0001 (HMO)

UHC Preferred Medicare Advantage FL-0002 (HMO)

UHC Preferred Medicare Advantage FL-002P (HMO)

Phone

Office Hours

UHC Preferred Complete Care FL-0003 (HMO C-SNP)

Phone

Office Hours

UHC Preferred Dual Complete FL-D001 (HMO D-SNP)

UHC Preferred Dual Complete FL-D01P (HMO D-SNP)

Phone

Office Hours

Or you can:

2. Enroll online by completing and submitting your enrollment form electronically!

Website

• Language Assistance / Non-Discrimination notice
• Asistencia de Idiomas / Aviso de no Discriminación

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage Plans: A Medicare Advantage organization with a Medicare contract. For Dual Special Needs Plans: A Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan's contract renewal with Medicare. Benefits, features and/or devices vary by plan/area. Limitations, exclusions and/or network restrictions may apply. $0 copays may be restricted to preferred home delivery prescriptions during the initial coverage phase and may not apply during the coverage gap or catastrophic stage. Food, OTC and utility benefits have expiration timeframes. Call your plan or review your Evidence of Coverage (EOC) for more information. Every year, Medicare evaluates plans based on a 5‐star rating system. Star rating is for 2024.

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H1045_230929_095951_M - Last Updated 10/1/2023 12:00:00 PM