Get Enrollment And Disenrollment Form - Kmap

Filling out the Enrollment and Disenrollment Form for KMAP can seem complex, but this guide will provide you with clear, step-by-step instructions to make the process easier. Whether you are enrolling in a health plan or disenrolling from one, this comprehensive overview will support you in completing the form accurately online.

Follow the steps to complete the form online:

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin with the top section if you are enrolling. Indicate your choice of health plan by marking the box next to one of the options: Coventry Health Care of Kansas, Inc., Unicare, or HealthConnect (only if applicable).
3. If changing Primary Providers for beneficiaries in HealthConnect, complete the section by providing the Primary Provider's name, Medicaid number, and phone number. Also, fill in the beneficiary’s name, Medicaid ID number, and telephone number.
4. Print the name of the beneficiary or casehead and ensure that the required signatures are provided: the beneficiary/casehead and the provider, along with the date.
5. If you are disenrolling a beneficiary, navigate to the bottom section of the form. Provide the provider's name, Medicaid number, phone number, and the beneficiary’s details the same way as in enrollment.
6. Select a reason for disenrollment from the provided options, ensuring it is appropriately marked. If necessary, include an explanation in the space provided.
7. Obtain the provider's signature for the disenrollment request and add the date.
8. After reviewing all entered information for accuracy, save your changes, and you may download, print, or share the completed form as required.

Complete your enrollment or disenrollment form online to ensure timely processing and access to health benefits.