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Disenrollment 2026
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- Click ‘Get Form’ to open the disenrollment form in the editor.
- Begin by entering your Last Name, First Name, and Middle Initial. Select your title (Mr., Mrs., Miss, Ms.) from the options provided.
- Fill in your Member ID and Birth Date. Indicate your Sex by selecting either Male or Female.
- Provide your Home Phone Number for any necessary follow-up communication.
- Read the agreement carefully regarding your disenrollment and ensure you understand the implications before signing and dating the form.
- If applicable, complete the section for authorized representatives by providing their Name, Address, Phone Number, and Relationship to Enrollee.
- Review the Attestation of Eligibility section. Check any boxes that apply to certify your eligibility for a Special Enrollment Period.
- Once all fields are completed accurately, submit the form via fax or mail as instructed on the document.
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