If you are working with a consumer that requests a non-subsidized, off-exchange plan, that enrollment application can be accessed below.

• Step 1 – Click the appropriate state link below (each state form is unique)
• Step 2 – Add agent name and NPN in the blank space on the last page of the enrollment form and provide to consumer (agent to assist consumer as needed)
• Step 3 – Consumer must sign and email completed PDF form to uhcops_be_exchanges@uhc.com or via U.S. Postal Service to the following address:

UnitedHealthcare
Community Plan
P.O. Box 30753
Salt Lake City, UT 84130

Please Note – The address on the application is NOT the address to return completed form. Please confirm with the consumer, if mailing hard copy, to return completed application to Salt Lake City, Utah, address above.

Texas consumers must complete and return both forms below.

Alabama

Arizona

Florida

Georgia

Illinois

Louisiana

Maryland

Michigan

North Carolina

Oklahoma

Tennessee

Texas

Texas (Disclosure Statement)

Virginia

Washington