Missing / Incomplete Application Update Request Form
THIS FORM IS FOR AGENT USE ONLY FOR MA/MAPD AND PDP PLANS
This form cannot be used for Medicare Supplement
Please complete ALL required fields marked with an asterisk (*) and mark the checkbox for information that
needs to be updated on the application.
*First: *MI: *Last Name:
Phone: *DOB: *Medicare Number:
Permanent Address:
Street Number: PO Box: Street Name:
City: State: Zip Code:
Mailing Address: (Check if same as Permanent Address)
Street Number: PO Box: Street Name:
City: State: Zip Code:
Part A Effective Date: Part B Effective Date:
Copy of Award Letter of Medicare Card: Proof of Part A: Proof of Part B:
Plan Name: Plan H-PBP (Contract):
Effective Date: Election Period: Qfiniti Transaction ID:
When using SEP provide reason:
*Agent Name: *Agent ID:
*Contact Name:
(Required if you are not Agent of Record (AOR))
*Agent Party ID, Tax Identification or National Producer #:
(Required if you are not Agent of Record (AOR))
*Email Address:
(where to send response)
Application Status: Missing Information/Verification Required: AOR Verification/Update:
Other:
Please be specific in what action is needed or what update/changes are being requested
Supporting Documents Attached:
Please remit this form to ICSSUPPORT@UHC.COM or fax to 866-802-6062
All emails containing Personal Health Information (PHI) or Personally Identifiable Information (PII) must be encrypted using
Secure Email Delivery before transmitting. 03052020
AGENT / SUBMITTER INFORMATION
