Get Disenrollment Form - Clover Health

This guide provides clear and step-by-step instructions on how to fill out the Disenrollment Form for Clover Health online. Whether you are familiar with the process or new to it, this comprehensive guide will support you through each section of the form.

Follow the steps to successfully complete the Disenrollment Form.

1. Press the ‘Get Form’ button to access the Disenrollment Form and open it in your online editor.
2. Review the eligibility criteria for disenrollment and check the boxes that apply to your situation. Ensure that you meet the requirements for a Special Election Period as outlined in the form.
3. Complete your personal information by entering your first name, middle initial, last name, birth date, and Medicare number in the designated fields.
4. Provide your home phone number. Ensure all information is accurate to avoid delays in processing your disenrollment request.
5. Read the statements carefully regarding the implications of disenrollment. You must understand that if you enroll in another Medicare plan, Clover Health membership will be cancelled.
6. Sign the form where indicated, along with the date of signing. If you are completing this form on behalf of another person, include the required details such as your name, street address, phone number, and relationship to the enrollee.
7. After completing the form, review all entries for accuracy and completeness. You can then save changes, download, or print the form for submission.
8. Submit the completed form via mail to the specified address or fax number provided on the form.

Start your disenrollment process by filling out the Disenrollment Form online today.