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  Member Forms & Resources

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***COVID-19*** There is an Emergency Declaration in place for the State of Florida and Nationally. We are here for you. Please click here to learn how Ultimate Health Plans provides benefits during an Emergency.

Below, please find Ultimate Health Plans’ most accessed forms and resources. If you can’t find what you’re looking for or if you need help, please call Member Services and we’ll be happy to assist you.

Prior Authorization for Medical Care

Some services are covered by our plan only if your PCP or other provider gets permission from Ultimate Health Plans first. This is called a Prior Authorization.

The PDF documents can be downloaded and then viewed with Adobe Reader.


Prescription Drug Forms

  • Reimbursement: If you paid out of pocket for a covered medication, send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Mail or fax your request for payment together with any bills or receipts to us with the contact information provided below:
    Direct Member Reimbursements
    P.O. Box 650287
    Dallas, TX 75265-0287
    You must submit your claim to us within 12 months of the date you received the service, item, or drug.
  • Prescription Drug Determination Requests
    The Prescription Drug Determination Request Form can be used for the following:
    • To request a prior authorization for a prescription drug that requires it.
    • To request a prior authorization for a drug designated as a high-risk medication.
    • To request that we cover a non-formulary drug.
    • To request that we waive quantity limit on a drug.
    • To request that a drug be covered at a lower tier.
    • To request that we waive the requirement to try an alternative drug “step therapy” first.
  • Appeals for Part D Prescription Drug Benefits:To file an appeal (request for redetermination) for a Medicare prescription drug denial please have your provider complete the form below:

Assessment of New Medical Technology

UHP has a formal process to evaluate and address new developments in technology and new applications of existing technology. We consider including new technology in our benefit plans to keep pace with changes and to ensure our members have equitable access to safe and effective care. To learn more about this formal process, please click on the link below:

Appointment of Representative

You can appoint someone to represent you in formal matters, such as appeals or grievances, by completing the form below:

Permission of Share Information (PSI)

Use this form if you want Ultimate Health Plans to share the information we have about you with another person or organization, such as a family member, friend, or other relative; someone who helps take care of you; or a social worker or health-care advocacy group.

Communicate Your Health Needs

If you're a new member, help us better understand your health needs and transition your care by completing and returning the form below:

Direct Member Reimbursement

To ask us for reimbursement on covered expenses you paid out of pocket for please download the form below and ask for your provider's help to complete it.

Advance Directives

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes). The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death.

Medicare law gives you the right to file a complaint with the Agency for Health Care Administration (AHCA) if you are dissatisfied with our process for handling Advance Directives.

To complete an advance directive, simply download the information and complete the forms in the document below. Make sure that your primary care doctor, attorney and the significant persons in your life know that you have an advance directive, and give them a copy. You may also want to keep a card or note in your purse or wallet that states that you have an advance directive and where it is located.
If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy. To download advance directives information and forms, please click on the following link:

Take Action BEFORE an Emergency to Stay Safe DURING a Crisis

If there is an emergency, do you know:

  • What you and your family will do?
  • What to have on hand?
  • What to take with you?
  • Where to go, if necessary?
  • What you would do with your pets?

Adult Preventive Guidelines

These Preventive Care Guidelines address routine health exams, diagnostic checkups, counseling and immunizations recommended for adults. Discuss these general guidelines with your doctor to stay as healthy as possible throughout the year.

This page was last modified: 3/12/2021 8:39:18 PM

Ultimate Health Plans is an HMO plan with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Ultimate Health Plans does not collect any member information through this website.


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