Get Disenrolling From Personal Choice Form

How to disenroll from Medicare Part A. If you pay a premium for Part A and wish to disenroll from Medicare Part A, visit your local Social Security office or by call 1-800-772-1213 (TTY 1-800-325-0778). You will need to fill out a CMS Form 1763 (Request for Termination of Premium Hospital and Medical Insurance).

You can voluntarily terminate your Medicare Part B (medical insurance). It is a serious decision. You must submit Form CMS-1763 (PDF, Download Adobe Reader) to the Social Security Administration (SSA). Visit or call the SSA (1-800-772-1213) to get this form.

"Disenrollment" means leaving Health Partners Medicare and no longer being a member. You may leave one of our plans because you decide that you want to leave. This is called voluntary disenrollment.

• Written by Anna Porretta. The Medicare Advantage Disenrollment Period (MADP) is when you can disenroll from a Medicare Advantage plan and return to Original Medicare. This period occurs every year from January 1 to February 14.

Rapid disenrollment occurs when a new enrollee switches to a different plan within the first few months of enrollment. The range of rapid disenrollment rates runs from less than 5% to as much as 30%. It is often driven by communication of benefit designs and of the changes occurring from one year to the next.

What Are Rapid Disenrollments? In Medicare lingo, a rapid disenrollment is generally when one of your clients, who you recently helped enroll into a new plan, decides to disenroll from their new plan within three months of their enrollment, or before their enrollment is final.

Disenrollment from a Medicare Advantage (Part C) or Medicare prescription drug (Part D) plan may occur automatically if you: Move your permanent residence out of the plan's service area (including incarceration). Lose your entitlement to Medicare benefits under Part A and/or are no longer enrolled in Part B.

For instance, beneficiaries may be required to disenroll if they change residences outside the plan's service area, lose Medicare eligibility, or if Medicare terminates a plan's contract. Beneficiaries also may be involuntarily disenrolled if they fail to pay premiums.