Get Fida Safe Discharge Disenrollment Confirmation Form - Health Ny

Filling out the FIDA Safe Discharge Disenrollment Confirmation Form is an essential step for individuals looking to disenroll from their current health plan. This guide provides a thorough walkthrough to help users complete the form accurately and effectively in an online format.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to obtain the FIDA Safe Discharge Disenrollment Confirmation Form and open it in the editing interface.
2. In Section 1, input the name of the plan you wish to leave. This step is crucial to ensure that the correct plan information is recorded.
3. Section 2 requires your personal information. Fill in your last name, first name, middle initial, date of birth, benefit ID, gender, and other relevant contact details including telephone number and permanent address.
4. If applicable, complete the Authorized Representative section by entering their last name, first name, relationship to you, and contact details, ensuring accurate representation.
5. In Section 3, articulate your reasons for wishing to leave your current plan and specify why you do not intend to enroll in another plan. Use the space provided to clear and detailed explanation.
6. Section 4 requires your signature. Read the informed consent statement carefully, understanding the implications of disenrolling, then sign and date the document to confirm your decision. An authorized representative should also sign this section if applicable.
7. Complete Section 5 by checking the box if the disenrollment request was made verbally. If so, provide the date verbal consent was received and the signature of the plan representative to finalize the process.
8. Once all sections of the form are complete, carefully review all the information for accuracy. Save your changes and proceed with downloading, printing, or sharing the completed form as needed.

Take action now and complete your FIDA Safe Discharge Disenrollment Confirmation Form online.