Plan disenrollment form 2026

1. Click ‘Get Form’ to open the plan disenrollment form in the editor.
2. Begin by entering your last name, first name, and middle initial in the designated fields. This information is crucial for identifying your account.
3. Select your title (Mr., Mrs., Miss, Ms.) and provide your Medicare number along with your birth date and sex (M/F). Ensure all details are accurate to avoid processing delays.
4. Input your home phone number in the specified format. This will help us contact you if there are any questions regarding your disenrollment.
5. Read the important information carefully before signing. Acknowledge that you understand the implications of disenrolling from Health First Medicare Plans.
6. Sign and date the form where indicated. If someone else is signing on your behalf, ensure they provide their name, address, phone number, and relationship to you.

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