By completing and signing this form, I authorize UCare to send me information about the following topics (please check all of the boxes that apply):
This authorization will expire when I disenroll from UCare health plans, unless I cancel this authorization earlier by sending written notice to UCare.
- I understand I have the right to cancel this authorization in writing at any time.
- I understand and agree that even if I cancel this authorization, information might have already been sent to me before I canceled the authorization.
- I understand I am not required to provide this authorization.
- I understand that my health coverage will not be affected if I do not provide this authorization.
- I understand this authorization does not allow UCare to release any protected health information about me to third parties.
- I understand I should retain a copy of this authorization for my records.
- I understand and agree to the terms in this authorization form.
A photocopy of this authorization will be treated in the same manner as an original.