Get Medicare Advantage Disenrollment Form - Priority Health

This guide will provide you with detailed instructions on how to fill out the Medicare Advantage Disenrollment Form for Priority Health online. By following these steps, you can ensure a smooth disenrollment process and address any questions you may have along the way.

Follow the steps to fill out the form correctly and efficiently

1. Press the ‘Get Form’ button to acquire the Medicare Advantage Disenrollment Form and open it in the editor.
2. Begin by completing your personal information in the designated fields. This includes your last name, first name, and middle initial.
3. Enter your Medicare number and home phone number in the specified fields.
4. Select your sex by checking the appropriate box for ‘Male’ or ‘Female.’
5. Provide your birth date in the month/date/year format.
6. Read the eligibility statements carefully and check the corresponding boxes that apply to your situation to certify your Election Period eligibility.
7. If applicable, complete the reason for disenrollment, including moving to a Long-Term Care Facility or joining another available program.
8. Understand the implications of your decision to disenroll as indicated in the instructions provided.
9. Sign and date the form. If someone is signing on your behalf, ensure the signature complies with state regulations and include the authorized representative's information.
10. After completing the form, save your changes, and proceed to download, print, or share the form as needed.

Complete the Medicare Advantage Disenrollment Form online for a seamless disenrollment experience.