Please submit data ONLY for UnitedHealthcare MA HMO plans.

First Name

Last Name

Home Phone

Date of Birth

Medicaid

UHC MA HMO Plan

Member ID

Plan Effective Date (XX/XX/XXXX)

Primary Care Doctor/Clinic

Agent Name (First Last)

Agency/Broker

Agent Phone (xxx-xxx-xxxx)

Event

Special Requests

Website

First Name

Last Name

Home Phone

Date of Birth

Medicaid

UHC MA HMO Plan

Member ID

Plan Effective Date (XX/XX/XXXX)

Primary Care Doctor/Clinic

Agent Name (First Last)

Agency/Broker

Agent Phone (xxx-xxx-xxxx)

Event

Special Requests

Website