Get Health Net CA66520 2010-2024

Contact us to verify your disenrollment before you seek medical services outside of Health Net Medicare Program s network. Health Net Medicare Programs employer group Disenrollment Form I f you request disenrollment you must continue to get all medical care from Health Net Medicare Programs until the effective date of disenrollment. Miss. Ms. Home Phone Number Please carefully read and complete the following information before signing and dating this disenrollment form If I have enrolled in another Medicare Advantage or Medicare Prescription Drug Plan I understand Medicare will cancel my current membership in Health Net Medicare Programs on the effective date of that new enrollment. We will notify you of your effective date after we get this form from you. Please fax this form to Health Net Medicare Programs Enrollment Services 818 337-7241 or mail to Last name First Name Medicare Birth Date Sex M Middle Initial F Mr. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future I may have to pay a higher premium for this coverage. Your Signature Date Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual as described above this signature certifies that 1 this person is authorized under State law to complete this disenrollment and 2 documentation of this authority is available upon request If you are the authorized representative you must provide the following information Name Address Phone Number - Relationship to Enrollee 6021756 CA66520 8/10 Material ID H0562EG20110043 Compliance Approved 09142010. .