Authorization to Receive Non-Plan Information

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.

Please indicate a program

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

UCare Member ID Number

First Name

Last Name

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

Today's Date

(Please click on the submit button only once, thank you.)

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage organizations to obtain their members’ consent to send members non-plan or non-health related information.

Completing this form and submitting it by clicking on the Submit button above allows you to receive information from UCare that may not be directly related to your health care or Medicare plan benefits.