Follow the steps to complete the disenrollment form successfully.

1. Click the ‘Get Form’ button to access the KPSA SKU 60050607 CA form and open it in the designated online form editor.
2. Begin by filling out your personal information. Enter your last name, first name, middle initial, and medical record number in the appropriate fields. Ensure accuracy to avoid complications.
3. Provide your mailing address, including city, state, and ZIP code. This information is crucial for communication regarding your disenrollment.
4. Enter your Medicare number and birth date in the specified fields. This helps verify your identity and enrollment in Kaiser Permanente.
5. Indicate your sex by selecting the appropriate option (M or F) in the designated section.
6. Choose a disenrollment reason from the provided options: moving out of the service area, joining another health plan, employer group coverage ending, or other (with an explanation).
7. Read the important information regarding the impact of disenrollment on your medical services. Acknowledge that you must continue to receive care from Kaiser Permanente until the effective date.
8. Provide your signature and the date to certify your request for disenrollment. If someone else is signing on your behalf, ensure they include their name, address, phone number, and relationship to you.
9. Follow instructions for returning the form. Send the signed white copy to Kaiser Permanente's Medicare Unit, and keep the yellow copy for your records. If applicable, send the pink copy to your employer group.
10. Once completed, save any changes made to your form. Then proceed to download, print, or securely share the form as needed.

Complete your disenrollment form online today to ensure a smooth transition.