Consent to Receive Non-Plan Information

Completing this form and submitting it by clicking on the Submit button below allows you to receive non-plan information from UCare. This is information unrelated to your health care or plan benefits.


* indicates required field.

Please indicate a program(s) *

Please enter your name, member number and email address for participation.

Member Number: *
Member Name:
*
First 		*
Last
Email: *

This consent will expire when I disenroll from UCare health plans, unless I cancel it.

  • I have the right to cancel in writing at any time.
  • If I cancel, information might have already been sent to me.
  • I am not required to consent.
  • My health coverage will not be affected if I do not consent.
  • This consent does not allow UCare to release any of my protected health information to third parties.
  • A photocopy of this consent will be treated the same as the original.

I understand and agree to the terms in this consent form.

Electronic Signature * 
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