Get Dis-enrollment Form - Lni Wa

Filling out the Dis-enrollment Form - Lni Wa is a straightforward process that enables users to formally notify of their disenrollment from the program. This guide provides step-by-step instructions to ensure a smooth and accurate submission of the form online.

Follow the steps to effectively complete your Dis-enrollment Form - Lni Wa.

1. Click the ‘Get Form’ button to obtain the Dis-enrollment Form - Lni Wa and open it for editing.
2. In the first section, enter the provider's name and L&I provider number(s). If applicable, include the name of the clinic or group, along with any group numbers associated.
3. Provide the name of the person making the disenrollment request from the clinic or group, along with the date of the request.
4. Select the reason for APP disenrollment from the listed options. Ensure to specify if applicable, why you are electing disenrollment while still practicing.
5. Fill in the last day of COHE participation in the specified format (MM/DD/YY).
6. If the provider has separated employment from your organization, check the relevant box indicating that the provider's L&I account should be inactivated.
7. Complete the section for the COHE representative submitting the request, by entering their name.
8. Once all fields are completed and double-checked for accuracy, you can save the changes, download, print, or share the Dis-enrollment Form as needed.

Begin your disenrollment process today by completing your Dis-enrollment Form - Lni Wa online.