Loading
Get Disenrollment Forms For Keystone 65
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Disenrollment Forms For Keystone 65 online
This guide provides step-by-step instructions for filling out the Disenrollment Forms for Keystone 65 online. Follow these clear directions to ensure your disenrollment request is completed accurately and efficiently.
Follow the steps to complete your disenrollment form successfully.
- Click ‘Get Form’ button to obtain the disenrollment form and open it for editing.
- Start filling out your personal information. Enter your last name, first name, and middle initial in the designated fields. Indicate your Medicare number and birth date accurately.
- Specify your sex by selecting either ‘M’ for male or ‘F’ for female. Provide your home phone number in the corresponding area.
- Carefully read the instructions on the form. Confirm whether you are disenrolling due to enrolling in another Medicare Advantage plan or Medicare Prescription Drug plan. Acknowledge the potential impact on your current membership.
- Sign and date the form. If someone is signing on your behalf, ensure that you provide their name, address, phone number, and their relationship to you.
- If applicable, check any statements that apply to your eligibility for disenrollment. This includes circumstances such as qualifying for help with Medicare premiums or moving to a long-term care facility.
- Once you have completed all sections, review the form for accuracy. When satisfied, save any changes you have made to ensure your information is not lost.
- Finally, you can either download or print the completed form for submission. If needed, share the form as directed in your instructions.
Ensure your disenrollment is processed smoothly by completing the Disenrollment Forms for Keystone 65 online today.
Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary care physician (PCP), who provides the services they need.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.