Get Disenrolling From Personal Choice Form

This guide provides clear and detailed instructions on how to fill out the Disenrolling From Personal Choice Form online. Whether you are a first-time user or familiar with digital forms, this walkthrough will help you understand each section of the form.

Follow the steps to complete your disenrollment process

1. Click ‘Get Form’ button to access the Disenrolling From Personal Choice Form and open it in your preferred online document editor.
2. Fill in your last name, first name, and middle initial in the designated fields. Ensure that the names match the information on your Medicare records.
3. Select your member ID from the corresponding section on the form. This number is crucial for identifying your records with Select Option PDP.
4. Enter your birth date in the format requested. This information is necessary for verifying your identity and eligibility.
5. Indicate your sex by selecting either the ‘M’ or ‘F’ box. This field is optional but may be used for processing your request.
6. Provide your home phone number, ensuring you include the area code in the designated format.
7. Review the statement regarding your consent for disenrollment. Ensure you understand the implications by reading through the text before proceeding.
8. Sign and date the form, ensuring your signature is clear. If someone other than you is signing, make sure to provide their relationship to you and authorization details.
9. If applicable, complete the section for an authorized representative, including their name, address, phone number, and relationship to you.
10. Carefully read the eligibility criteria listed in the following sections. Check any boxes that may apply to your situation to certify your eligibility.
11. Finally, save your changes, and then download, print, or share the completed form as needed to submit it to the relevant authority.

Complete your disenrollment form online to ensure a smooth and timely processing of your request.