Get Disenrollment Letter

Completing the Disenrollment Letter online is a straightforward process that requires attention to key details. This guide will walk you through each section of the letter, ensuring you have the necessary information to submit your request successfully.

Follow the steps to fill out the Disenrollment Letter online.

1. Click ‘Get Form’ button to obtain the Disenrollment Letter and open it in your preferred document editor.
2. Begin filling out your personal information in the designated fields. Enter your last name, first name, middle initial, and member ID as indicated on the form.
3. Provide your birth date and permanent residence information, including your street address, city, state, and ZIP code.
4. Select your sex by checking the appropriate box (male or female) and provide your home phone number in the format requested.
5. Review the disenrollment periods mentioned in the form. Confirm your eligibility by checking any statements that apply to your situation and provide necessary details, such as dates.
6. Carefully read the conditions of disenrollment. If applicable, note that enrolling in another Medicare Advantage or prescription drug plan will affect your current coverage.
7. Sign and date the form. If you are signing on behalf of someone else, provide the authorized representative's information, including name, address, phone number, and relationship to the enrollee.
8. After completing the form, save your changes. You can then choose to download, print, or share the Disenrollment Letter as needed prior to mailing or faxing it.

Ensure your disenrollment request is completed correctly by following these steps online.