Get Direct Primary Care Membership Cancellation Form

This guide provides clear and supportive instructions on how to complete the Direct Primary Care Membership Cancellation Form online. Whether you are looking to cancel your membership due to financial reasons or personal choices, we will walk you through each step in a user-friendly manner.

Follow the steps to complete your cancellation form effortlessly.

1. Press the ‘Get Form’ button to obtain the cancellation form and access it in the online editor.
2. Begin by filling in your last name and first name in the designated fields.
3. Indicate your sex by selecting the appropriate checkbox for either male or female.
4. Enter your date of birth, ensuring that it is formatted correctly.
5. Provide your complete home address, including city, state, and ZIP code.
6. Input your phone number, including the area code.
7. Add your middle initial if applicable.
8. Enter your Direct Primary Care (DPC) number found on your Direct Primary Care card.
9. Fill in your email address to receive confirmation regarding your cancellation.
10. If you wish to cancel additional memberships, utilize the space provided on the back of the form.
11. Specify the cancellation date; this can be the date EverMed Services, LLC receives your signed form or a later date of your choosing.
12. Select the reasons for your cancellation by checking all applicable boxes.
13. Sign and print your name at the bottom of the form, confirming that you have read and understand the cancellation policy.
14. Make sure to include the date of signing the form.
15. After filling out the form, you have the option to save changes, download, print, or share the completed form.

Complete your cancellation process online today for an efficient experience.