Member Forms
2025 Medicare Plan Application
Prescription Claim Form
Claim Forms
- D-SNP OTC & Healthy Food Claim FormOpen a PDF
- Medicare Advantage Flex Card Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- 2024 Silver&Fit Claim Form - Use this form for out-of-network claims for plan year 2024
- Medicare Advantage Transplant Travel and Lodging Claim formOpen a PDF
- D-SNP Transplant Travel and Lodging Claim formOpen a PDF
- Dental Claim Form
General Forms
- Manage Your Privacy
- New York Health Care Proxy form (PDF)Open a PDF
- New York Health Care Proxy form - Spanish (PDF)Open a PDF
Other Forms
Univera Healthcare is an HMO/PPO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Medicaid program. Enrollment in Univera Healthcare depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_10520_C.
This page last updated 10-01-2024.
