Get Aetna Disenrollment Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Aetna disenrollment form online
Completing the Aetna disenrollment form online can seem daunting, but with the right guidance, it becomes a straightforward process. This guide provides clear instructions to assist users in effectively filling out each section of the form.
Follow the steps to complete the Aetna disenrollment form online
- Click ‘Get Form’ button to obtain the disenrollment form and open it for online completion.
- Begin by filling out the retiree information section. Enter your name in the format of last name, first name, and middle initial. Provide your Social Security number, address (street, city, state, ZIP), and telephone number. Ensure all details are accurate.
- Indicate your date of birth and, if you are a Kaiser member, include your medical record number.
- Select the reason for disenrollment from the provided options. If applicable, specify your effective date for disenrollment based on your selected reason.
- In the section asking for disenrollment requests, clearly write your first name and last name, followed by the name of your current Medicare Advantage plan.
- List any family members you wish to disenroll from the current plan. For each individual, provide their name, relationship to you, sex, date of birth, and Social Security/ID number.
- All required signatures must be completed. Ensure that you sign the form, and if applicable, have your enrolled spouse or family member who is eligible for Medicare sign as well.
- Once you have filled out all sections and secured the necessary signatures, review the form for accuracy. Save your changes, and then download or print the completed form.
- Return the completed form to the Medicare Advantage medical plan you are leaving, and keep a duplicate copy for your records.
Complete your disenrollment form online today for a smooth transition.
Get form
In some circumstances, disenrollment is voluntary; in others, beneficiaries are forced to disenroll. 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.
Get This Form Now!
Fill Aetna Disenrollment Form
No information is available for this page. If you request disenrollment, you must continue to get all medical care from Aetna Medicare until the effective date of disenrollment. Once your disenrollment is effective, you will utilize your MHBP ID card to access prescription medicines. Simply use this form to terminate from the current contracted location. Need to terminate a full contract? Leave or cancel your plan (disenrollment). How do I fill this out? How do I submit a disenrollment request?
Industry-leading security and compliance
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.