Kaiser permanente individual family plan disenrollment request form 2026

1. Click ‘Get Form’ to open the Kaiser Permanente Individual Family Plan Disenrollment Request Form in the editor.
2. Begin by entering your personal information. Fill in your last name, first name, middle initial, medical record number, mailing address, Medicare number, birth date, city, state, and zip code. Ensure all details are accurate for a smooth process.
3. Select your sex and provide your home phone number. This information is essential for identification purposes.
4. Choose a disenrollment reason from the provided options. If you select 'Other,' be sure to explain your reason clearly in the space provided.
5. Read through the important notes regarding disenrollment carefully. This section outlines critical information about your current coverage and future options.
6. Sign and date the form at the bottom. If someone else is signing on your behalf, ensure they provide their details as an authorized representative.
7. Finally, return the signed white copy to Kaiser Permanente’s Medicare Unit as instructed. Keep the pink and yellow copies for your records.

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