Uhcmv0895 form 2025

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The document is a TRICARE Prime Reconsideration Request Form, which allows sponsors to request reinstatement, reenrollment, or retroactive enrollment of their health coverage. It includes sections for personal information, the specific action requested, detailed explanations for reconsideration, and supporting documentation requirements. Additionally, it provides an Electronic Payment Authorization Form for setting up automatic premium payments. The document emphasizes the importance of privacy and outlines the consequences of violations.

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Click ‘Get Form’ to open the uhcmv0895 form in the editor.
Begin by filling out the TRICARE Prime Sponsor Information section. Enter your last name, first name, middle initial, and SSN or DBN. Provide your home and mailing addresses, including city, state, and ZIP code.
Specify the action you are requesting in Step 1. Choose from options like reinstating coverage or reenrolling coverage by checking the appropriate box.
In Step 2, provide a detailed explanation for your request and list each person to be reinstated or reenrolled. If more space is needed, attach an additional page.
For Step 3, gather any supporting documentation required for your request and ensure it is ready for submission.
Sign the form in Step 4. The signature must be from the sponsor, spouse, or legal guardian of the beneficiary.
Finally, mail or fax the completed form to UnitedHealthcare Military & Veterans using the provided address or fax number in Step 5.

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