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Get Disenrollment Letter

You must continue to get all medical care from Anthem Medicare Preferred Standard (PPO) until the effective date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of Anthem Medicare Preferred Standard (PPO) s network. We will notify you of your effective date after we get this form from you. Last Name: First Name: Middle Mr. o Mrs. o Initial: o Miss o Ms. Member ID: Birth Date: Permanent Residence: Street Address.

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