Enrollee/dependent Level Medicare Status Change Form - Unitedhealthcare printable pdf download

Enrollee/Dependent Level Medicare Status Change Form

In order to accurately represent your Medicare information, please provide the following information.

Please indicate the following information listed on your UnitedHealthcare ID card:

UnitedHealthcare Enrollee Name: ______________________________________________________

UnitedHealthcare 9-digit Subscriber ID Number: __________________________________________

UnitedHealthcare 6-digit Group Number: ________________________________________________

Have you, your spouse or dependent(s) enrolled in Medicare Part B (Medicare Medical Insurance)?

• If Yes – Complete both sections 1 and 2

• If No – Complete section 2

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Section 1

Please indicate the reason you, your spouse or dependent(s) have enrolled in Medicare Part B (Medicare Medical

Insurance).

Age 65

Disability (under age 65)

Indicate the date of total disability as determined by Medicare: __________________________

End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant)

Indicate where dialysis is completed:

Home

Facility

Indicate the number of months of consecutive dialysis based on location of dialysis:

Home dialysis and 30 or less consecutive months

Home dialysis and 31 or more consecutive months

Facility dialysis and 33 or less consecutive months

Facility dialysis and 34 or more consecutive months

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Section 2

Signature_______________________________________________________________ Date ___________

Please sign and date this form, and return it along with a copy of any applicable Medicare card (if enrolled in Medicare

Part B) to the following address:

UnitedHealthcare Eligibility

P.O. Box 1946

Oldsmar, FL 34677-1918

Fax (813) 818-3724

Revised 12/10/04

Enrollee/dependent Level Medicare Status Change Form - Unitedhealthcare