Follow the steps to successfully complete your disenrollment form.

1. Click ‘Get Form’ button to obtain the disenrollment form and open it in your preferred online editor.
2. Fill in your last name, first name, and middle initial in the designated fields. Provide your member ID and birth date as required.
3. Indicate your gender by selecting the appropriate box next to 'Sex'. Use 'M' for male and 'F' for female.
4. Enter your home phone number in the provided space, including the area code.
5. Read the statement that explains the implications of your request. Check the box indicating your agreement to the terms and conditions outlined.
6. Sign your name in the signature field provided. You may also include the date you are completing the form.
7. If you are an authorized representative signing on behalf of the individual, fill in your name, address, phone number, and your relationship to the enrollee.
8. Review the attestation section and check any applicable boxes that certify your eligibility for a special enrollment period.
9. If applicable, provide dates for any changes related to Medicaid or other coverage in the designated areas.
10. Once you have completed the form, review it for accuracy. Then, save your changes, download, or print the form for your records.
11. Submit the completed form as advised. You can either send it back in the enclosed envelope or fax it to the specified number.

Complete your disenrollment request online today for a simple and efficient process.