Get Silverscript Disenrollment Form

This guide provides step-by-step instructions on how to fill out the Silverscript Disenrollment Form online. Following these clear steps will help ensure a smooth and efficient disenrollment process.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to download the form and open it in your editor.
2. Begin by filling in your last name, first name, and middle initial in the designated fields. This information identifies you accurately.
3. Enter your Member ID. This number is important for processing your disenrollment.
4. Provide your birth date in the specified format. This helps to verify your identity.
5. Select your sex by checking the corresponding option (M or F).
6. Input your home phone number in the designated area, ensuring it is formatted correctly.
7. Read the agreement carefully. By completing this disenrollment request, you consent to the terms regarding your coverage and effective disenrollment date.
8. Sign and date the form in the areas provided at the bottom. If you are filling this out on behalf of the enrollee, ensure you provide your name, address, phone number, and relationship to the enrollee.
9. Review all the information you have entered to ensure accuracy. This is a crucial step to prevent any discrepancies.
10. Once all fields are completed and verified, you can save changes, download, print, or share the completed form as needed.

Begin completing your Silverscript Disenrollment Form online today to ensure a smooth transition.