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February 15 – September 30 | 8 am – 8 pm EST | Monday – Friday
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Medical Forms

Click the name of the form to view each document.

Appointment of Representative Form Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals.

Case Management
Enrollment & Intervention Consent Form

To enroll in our Case Management Program, you or your authorized representative can download this form, complete it and either mail it or fax it to us at the address and/or fax number below.

University of Maryland Health Advantage
Attention: Health Services Department
1966 Greenspring Drive, Suite 100
Timonium, MD 21093

Fax: 1-844-328-5952
Member Medical Reimbursement Form Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
PCP Change Request Form

You can use this form to request a change in your Primary Care Physician (PCP)

Fax to:   1-844-329-1085

Mail to:  University of Maryland Health Advantage
             Attention: Enrollment Department
             1966 Greenspring Drive, Suite 100
             Timonium, MD 21093

Request for a Reconsideration (Appeal) Use this form to request an appeal of University of Maryland Health Advantage’s denial of coverage and/or payment of medical and/or hospital services.