Get Kaiser Senior Advantage Disenrollment Form - California's Valued ... - Cvtrust

Filling out the Kaiser Senior Advantage Disenrollment Form can seem daunting, but this guide will simplify the process. Follow these steps to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the disenrollment form.

1. Press the ‘Get Form’ button to access the Kaiser Senior Advantage Disenrollment Form and open it for editing.
2. Provide your personal information: Carefully fill in your last name, first name, middle initial, medical record number, mailing address, Medicare number, birth date, city, state, zip code, and home phone number.
3. Indicate your sex by selecting 'M' for male or 'F' for female.
4. Select a reason for disenrollment from the options provided: moving out of the service area, joining another health plan, employer group coverage has ended, or other. If selecting 'Other', make sure to provide a clear explanation.
5. Review the following statements regarding disenrollment and your potential impacts on Medicare coverage, ensuring you fully understand them before proceeding.
6. Sign and date the form at the designated area to complete your request. If you are signing on behalf of another individual, ensure that you provide the name, address, phone number, and relationship to the enrollee.
7. Return the signed white copy of the form to Kaiser Permanente at the address provided. If applicable, send the pink copy to your employer group or union/trust fund and keep the yellow copy for your records.
8. After submitting the form, save any changes, download a copy for your records, print the filled form, or share it with any relevant parties.

Take control of your healthcare by filling out the Kaiser Senior Advantage Disenrollment Form online today.