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Disenrollment letter 2026
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- Click ‘Get Form’ to open the disenrollment letter in the editor.
- Begin by filling in your personal information. Enter your last name, first name, middle initial, and member ID. Ensure that your birth date is accurate.
- Provide your permanent residence details including street address, city, state, and ZIP code. Select your sex from the options provided.
- Input your home phone number for any necessary follow-up communications.
- Review the eligibility statements carefully. Check any boxes that apply to you to certify your eligibility for disenrollment.
- Sign and date the form at the bottom. If someone else is signing on your behalf, ensure they provide their information as well.
- Once completed, save the document and either mail it to the Enrollment Processing Center or fax it using the provided number.
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