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

Notes to HeathTexas

Website

Please review the form.

First Name (required)

Last Name (required)

Home Phone

Date of Birth

Medicaid

UHC MA HMO Plan

Member ID

Plan Effective Date (XX/XX/XXXX)

Primary Care Doctor/Clinic

Agent Name (Last, First)

Agency/Broker

Agent Phone (xxx-xxx-xxxx)

Event

Notes to HeathTexas

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