Disenrollment 2026

1. Click ‘Get Form’ to open the disenrollment form in the editor.
2. Begin by entering your Last Name, First Name, and Middle Initial. Select your title (Mr., Mrs., Miss, Ms.) from the options provided.
3. Fill in your Member ID and Birth Date. Indicate your Sex by selecting either Male or Female.
4. Provide your Home Phone Number for any necessary follow-up communication.
5. Read the agreement carefully regarding your disenrollment and ensure you understand the implications before signing and dating the form.
6. If applicable, complete the section for authorized representatives by providing their Name, Address, Phone Number, and Relationship to Enrollee.
7. Review the Attestation of Eligibility section. Check any boxes that apply to certify your eligibility for a Special Enrollment Period.
8. Once all fields are completed accurately, submit the form via fax or mail as instructed on the document.

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