Below is a list of forms used in day-to-day interactions with our Plan. Visit this section regularly to ensure you have the latest copy.
Forms
Last updated 05/06/2020
Helpful Links
CMS Model Electronic Complaint Form
The Medicare Beneficiary Ombudsman
Unable to view PDFs? Click here
Benefits During Disasters and Catastrophic Events
Click here for Multi-Language Interpreter Service
Servicios de interpretación en varios idiomas
(Multi-Language Insert) | (Inserción de varios idiomas)
Section 1557 Notice of Non-Discrimination: English | Spanish
Hours
From October 1 to March 31, we are open 7 days a week from 8 a.m. to 8 p.m. EST.
From April 1 to September 30, we are open Monday through Friday, 8 a.m. to 8 p.m. EST.
Telephone 
Toll Free 1-866-245-5360
TTY/TDD: 711
Physical Address
5403 N Church Ave
Tampa, FL 33614
Serving the following areas in Florida:
- Brevard County:
Includes Cape Canaveral, Cocoa Beach, Cocoa, Indian Harbour Beach, Melbourne, Palm Bay, Rockledge, Satellite Beach, Sebastian, Titusville and West Melbourne, Florida
- Broward County:
Includes Coconut Creek, Cooper City, Coral Springs, Dania Beach, Deerfield Beach, Fort Lauderdale, Hallandale Beach, Hollywood, Lauderdale Lakes, Lauderhill, Lighthouse Point, Margate, Miramar, North Lauderdale, Oakland Park, Parkland, Pembroke Pines, Plantation, Pompano Beach, Sunrise, Tamarac, West Park, Weston and Wilton Manors, Florida
- Citrus County:
Includes Crystal River, Inverness, Beverly Hills, Black Diamond, Citrus Hills, Citrus Springs, Floral City, Hernando, Homosassa, Homosassa Springs, Inverness Highlands North, Inverness Highlands South, Lecanto, Pine Ridge, Sugarmill Woods, Chassahowitzka and Holder, Florida
- Charlotte County:
Includes Punta Gorda, Charlotte Harbor, Charlotte Park, Cleveland, Englewood, Grove City, Harbour Heights, Manasota Key, Port Charlotte, Rotonda, Solana, Adrian Town, Boca Grande and Cape Haze, Florida
- Collier County:
Includes Everglades City, Marco Island and Naples, Florida
- Hernando County:
Includes Aripeka, Bayport, Brookridge, Brooksville, Garden Grove Estates, Hernando Beach, High Point, Hill n Dale, Istachatte, Lake Lindsey, Masaryktown, Nobleton, North Brooksville, North Weeki Wachee, Pine Island, Ridge Manor, Ridge Manor West, South Brooksville, Spring Hill, Spring Lake, Weeki Wachee and Weeki Wachee Gardens, Florida
- Hillsborough County:
Includes Plant City, Tampa, Temple Terrace, Apollo Beach, Balm, Bloomingdale, Boyette, Brandon, Carrollwood, Cheval, Citrus Park, Dover, East Lake-Orient Park, Egypt Lake-Leto, Fish Hawk, Gibsonton, Keystone, Lake Magdalene, Lutz, Mango, Northdale, Palm River-Clair Mel, Pebble Creek, Progress Village, Riverview, Ruskin, Seffner, Sun City Center, Thonotosassa, Town 'n' Country, University, Valrico, Westchase and Wimauma, Florida
- Indian River County:
- Includes Fellsmere, Sebastian, Vero Beach, Indian River Shores, Orchid, Florida Ridge, Gifford, Roseland, South Beach, Vero Beach South, Wabasso, Wabasso Beach, West Vero Corridor, Windsor (formerly North Beach) and Winter Beach, Florida
- Lake County:
- Includes Clermont, Eustis, Fruitland Park, Groveland, Leesburg, Mascotte, Minneola, Mount Dora, Tavares, Umatilla, Astatula, Howey-in-the-Hills, Lady Lake, Montverde, Altoona, Astor, Ferndale, Four Corners, Lake Kathryn, Lake, Mack-Forest Hills, Lisbon, Mount Plymouth, Okahumpka, Paisley, Pine Lakes, Pittman, Silver Lake, Sorrento and Yalaha, Florida
- Lee County:
- Includes Bonita Springs, Cape Coral, Fort Myers, Sanibel, Fort Myers Beach, Estero, Alva, Bokeelia, Buckingham, Burnt Store Marina, Captiva, Charleston Park, Cypress Lake, East Dunbar, Fort Myers Shores, Gateway, Harlem Heights, Iona, Lehigh Acres, Lochmoor Waterway Estates, Matlacha (on Matlacha Island), Matlacha Isles-Matlacha Shores, McGregor, North Fort Myers, Olga, Page Park, Palmona Park, Pine Island Center, Pine Manor, Pineland (on Pine Island), Punta Rassa, San Carlos Park, St. James City, Suncoast Estates and Tanglewood, Florida
- Marion County:
- Includes Belleview, Dunnellon, Ocala, McIntosh, Reddick, Silver Springs Shores and The Villages (with Sumter County), Florida
- Manatee County:
- Includes Anna Maria, Bradenton, Bradenton Beach, Holmes Beach, Palmetto, Longboat Key, Bayshore Gardens, Cortez, Ellenton, Memphis, Samoset, South Bradenton, West Bradenton, West Samoset, Whitfield, Duette, Village of the Arts, Myakka City, Oneco, Parrish, Terra Ceia, Rubonia, Gillette, Palm View, Memphis Heights, Palma Sola, Manavista, Fort Hamer, Manhattan, Oak Knoll, Waterbury, Verna, Marsh Island, Snead Island, Rattlesnake Key, Rye, Elwood Park, Ward Lake and Cedar Hammock, Florida
- Martin County:
- Includes Stuart, Jupiter Island, Ocean Breeze, Sewall's Point, Indiantown, Hobe Sound, Jensen Beach, North River Shores, Palm City, Port Salerno, Rio, Hutchinson Island and Port Mayaca, Florida
- Orange County:
- Includes Apopka, Bay Lake, Belle Isle, Edgewood, Lake Buena Vista, Maitland, Ocoee, Orlando, Winter Garden, Winter Park, Eatonville, Oakland and Windermere, Florida
- Osceola County:
- Includes Kissimmee, St. Cloud, Buenaventura Lakes, Campbell, Celebration, Four Corners, Poinciana, Yeehaw Junction, Bull Creek, Deer Park and Harmony, Florida
- Palm Beach County:
- Includes Atlantis, Belle Glade, Boca Raton, Boynton Beach, Briny Breezes, Cloud Lake, Delray Beach, Glen Ridge, Golf, Greenacres, Gulf Stream, Haverhill, Highland Beach, Hypoluxo, Juno Beach, Jupiter, Jupiter Inlet Colony, Lake Clarke Shores, Lake Park, Lake Worth, Lantana, Loxahatchee Groves, Manalapan, Mangonia Park, North Palm Beach, Ocean Ridge, Pahokee, Palm Beach, Palm Beach Gardens, Palm Beach Shores, Palm Springs, Riviera Beach, Royal Palm Beach, South Bay, South Palm Beach, Tequesta, Wellington, Westlake and West Palm Beach, Florida
- Pasco County:
- Includes Dade City, Port Richey, New Port Richey, San Antonio, Zephyrhills, St. Leo, Aripeka, Bayonet Point, Beacon Square, Connerton, Crystal Springs, Dade City North, Elfers, Heritage Pines, Holiday, Hudson, Jasmine Estates, Key Vista, Lacoochee, Land O' Lakes, Meadow Oaks, Odessa, Pasadena Hills, Quail Ridge, River Ridge, Shady Hills, Trinity and Trilby, Florida
- Pinellas County:
- Includes Belleair, Belleair Beach, Belleair Bluffs, Clearwater, Dunedin, Gulfport, Indian Rocks Beach, Largo, Madeira Beach, Oldsmar, Pinellas Park, Safety Harbor, Seminole, South Pasadena, St. Pete Beach, St. Petersburg, Tarpon Springs, Treasure Island, Indian Shores, Kenneth City, Redington Beach, Redington Shores, Bardmoor, Bay Pines, Bear Creek, East Lake, Feather Sound, Greenbriar, Harbor Bluffs, Lealman, Palm Harbor, Ridgecrest, South Highpoint and Tierra Verde, Florida
- Polk County:
- Includes Auburndale, Bartow, Davenport, Eagle Lake, Fort Meade, Frostproof, Haines City, Lake Alfred, Lakeland, Lake Wales, Mulberry, Polk City, Winter Haven, Dundee, Hillcrest Heights, Lake Hamilton, Highland Park, Alturas, Babson Park, Bradley Junction, Combee Settlement, Crooked Lake Park, Crystal Lake, Cypress Gardens, Four Corners, Fuller Heights, Fussels Corner, Grenelefe, Highland City, Homeland, Inwood, Jan Phyl Village, Kathleen, Lakeland, Highlands, Loughman, Medulla and Poinciana, Florida
- Saint Lucie County:
- Includes Fort Pierce, Port St. Lucie, St. Lucie Village. Fort Pierce North, Fort Pierce South, South Hutchinson Island, Indian River Estates, Lakewood Park, River Park, White City and Viking, Florida
- Sarasota County:
- Includes Sarasota, Venice, North Port, Longboat Key, Desoto Lakes, Englewood, Fruitville, Gulf Gate Estates and Laurel, Florida
- Seminole County:
- Includes Altamonte Springs, Casselberry, Lake Mary, Longwood, Oviedo, Sanford, Winter Springs, Black Hammock, Chuluota, Fern Park, Forest City, Geneva, Goldenrod (with Orange County), Heathrow, Midway, Wekiwa Springs, Bertha, Indian Mound Village, Lake Monroe, Slavia, Sanlando Springs and Taintsville, Florida
- Sumter County:
- Includes Bushnell, Center Hill, Coleman, Webster, Wildwood, Lake Panasoffkee, The Villages, Croom-A-Coochee, Linden, Mabel, Oak Grove, Orange Home, Oxford, Royal, Rutland, St. Catherine, Sumterville, Tarrytown, Wahoo
- Volusia County:
- Includes Daytona Beach, Daytona Beach Shores, DeBary, DeLand, Deltona, Edgewater, Holly Hill, Lake Helen, New Smyrna Beach, Oak Hill, Orange City, Ormond Beach, Port Orange, South Daytona, Pierson, Ponce Inlet, DeLand Southwest, De Leon Springs, Glencoe, North DeLand, Ormond-by-the-Sea, Samsula-Spruce Creek, Seville, West DeLand, Alamana, Allandale, Ariel, Bakerstown, Barberville, Benson Junction, Beresford, Bethune Beach, Blake, Blue Springs Landing, Bluffton, Boden, Cassadaga, Cabbage Bluff, Connersville, Conrad, Cow Creek, Creighton, Cypress Lake Estates, Daisy Lake, Daytona Highridge Estates, Daytona Park Estates, Deadman Landing, DeLand Highlands, DeLeon Springs Heights, Edgewater Junction, Eldora, Eldridge, Ellinor Village, Emporia, Enterprise, Farmton, Fatio, Fort Florida, Glenwood, Halifax Estates, Harbor Oaks, Hucomer, Isleboro, Kalamazoo, Lake Ashby Shores, Lemon Bluff, Maytown, Mission City, Mound Grove, National Gardens, Florida, Orange City Hills, Ortona, Osteen, Packwood Place, Pennichaw, Riverside, Seabreeze and Senyah, Florida
Optimum HealthCare, Inc. is an HMO with a Medicare contract and a contract with the state of Florida Medicaid program. Enrollment in Optimum HealthCare, Inc. depends on contract renewal. This Information is not a complete description of benefits. Call 1-866-245-5360 (TTY: 711) for more information. Medicare beneficiaries may also enroll in Optimum HealthCare through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system
Optimum HealthCare has been approved by the National Committee for Quality Assurance (NCQA) to operate Chronic Special Needs Plan (SNP) Plans until December 2020 and Dual Special Needs Plan (SNP) Plans until December 2021 based on a review of Optimum HealthCare’s Model of Care.
Optimum HealthCare, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Optimum HealthCare, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Optimum HealthCare, Inc. konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-245-5360 (TTY: 711). Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-245-5360 (TTY: 711).
These materials may be made available in alternate formats (e.g., large print, Braille) to individuals with disabilities, upon request.