Member Name:
*
First
*
Last
Member Number:
*
Email:
(Optional: For an e-mail confirmation.)
Address:
Street
 *
City
State
Zip
Phone:
(XXXXXXXXXX) no hyphens
Contact Preference: *  

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.
 
Signature of Member
(Type your full name)
Date
Signature of parent, guardian or authorized representative
(Type your full name)
Date
(indicate applicable authority to sign on behalf of member)
* indicates required field.