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Member Forms

Member Authorization Form – You can fill out the Member Authorization form to designate someone to receive your protected health information (PHI). It includes instructions on how to complete the authorization form.

Claim Form – You can complete this form online and print it from your computer. You'll also find helpful information on how to file a claim.

Fitness Club Reimbursement Form – You can get reimbursed for up to $100* per family on your membership at a fitness club. The reimbursement is paid once per plan year, to the Plan enrollee, upon proof of membership and payment. Use our fitness club reimbursement form to request your reimbursement. Check the instructions for details on the types of fitness clubs that qualify under this benefit and how to complete the reimbursement form.

* Medicare Extension members are eligible for reimbursement up to $100 per enrollee per plan year for a fitness club membership.

Diabetes Prevention Program Reimbursement Form (for non-Medicare members only) – You can get reimbursed up to $500 when you complete 20 or more sessions in an approved diabetes prevention program. See the reimbursement form for details.

Other Health Insurance Form – If you have medical benefits under another health plan in addition to the UniCare State Indemnity Plan, you need to let us know by completing our Other Health Insurance form.

Not sure which plan you’re in? You’ll find your plan name on the front of your ID card, under your member ID number.

Other materials available by mail

Visit our Request Printed Plan Materials page for a list of additional member materials you can order by email using our online order form. We will mail them to you promptly.


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For self-funded plans, claims are administered by UniCare Life & Health Insurance Company. © 2000-2020 UniCare.