Useful Forms
Click on form name to access and download.
Appointing a Representative Form
If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.
Download Appointing a Representative Form
Direct Claim Form
Submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency. You must submit claims within 12 months of date of purchase.
Download Direct Claim Form (PDF file)
Medco Mail Order
Receive your drug prescriptions through the mail.
Download Medco Mail Order (PDF file)
Health & Allergy Questionnaire
Download Health & Allergy Questionnaire (PDF file)
Request for Medicare Prescription Drug Coverage Determination Form
Request formulary or tiering exception, prior authorization for a drug, or file an appeal.
Download Request for Medicare Prescription Drug Coverage Determination Form
Mail completed form to:
United American Insurance Company
Attn: Group Part D Information
P.O. Box 8080
McKinney, TX 75070
Vaccine and Administration Form
For reimbursement of covered Part D vaccines and their administration (injection).
Download Vaccine and Administration Form (PDF file)
For your Medicare Part D questions and needs, please let us know how we can assist you.
Contact Us.
Note: You must have Adobe Reader version 5.0 or higher installed on your computer in order to view and print the above file properly. Click here to download a FREE COPY of Adobe Reader.
Updated 10/01/11