Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Name of Medicaid Client' field. This identifies you as the individual opting out.
3. In the 'Name of Health Home' section, specify the health home you are eligible for, if applicable.
4. Next, provide the 'Name of Medicaid Managed Care Plan' to indicate which plan you are currently enrolled in.
5. Fill out the 'Reason for Opting Out' section with a brief explanation of your decision.
6. Sign and date where indicated as the Medicaid client. If applicable, have your parent, guardian, or legally authorized representative sign as well.
7. Finally, ensure that both the Health Home Care Manager and Medicaid Managed Care Plan Representative sign and date their respective sections.

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