Member Forms
2025 Medicare Plan Application
2024 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
Other Forms
Univera Healthcare is an HMO plan and PPO plan with a Medicare contract. 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.
