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Disenrollment Form Health First Insurance 2026
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- Click ‘Get Form’ to open the Disenrollment Form Health First Insurance in the editor.
- Begin by entering your Member ID number in the designated field at the top of the form.
- Next, print your full name clearly in the 'Member Name' section, including first, middle, and last names.
- Fill in your address details accurately, including street, city, state, zip code, and county.
- Provide your home telephone number and indicate your gender by checking either 'Male' or 'Female'.
- Enter your date of birth and specify the requested disenrollment date.
- Select a reason for disenrollment from the options provided on the form.
- Sign and date the form. If someone else is signing on your behalf, ensure they provide their information as an authorized representative.
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Related links
To disenroll from a medicare advantage (MA) plan, The forms must be received no later than 60 days after the event occurs,
you can contact your local County Human Services Office and ask them to close your case. Contact Center 800-221-3943 / State Relay: 711