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Get Mcha Cancellation Form

Please Mail Complete Form to MCHA/Medica Mn015-2838 4316 Rice Lake Road Duluth MN 55811 Or Fax Complete Form to MCHA/Medica Enrollment at 218-279-6493 CANCELLATION FORM Name MCHA Member Number Street Address Medicare Number City State Zip Code Birth date month/day/year MCHA terminates coverage the end of the month in which the Cancellation Form is received by MCHA or on the date of death. If MCHA premiums are automatically withdrawn from a bank a.

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