Disenrollment letter 2026

1. Click ‘Get Form’ to open the disenrollment letter in the editor.
2. 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.
3. Provide your permanent residence details including street address, city, state, and ZIP code. Select your sex from the options provided.
4. Input your home phone number for any necessary follow-up communications.
5. Review the eligibility statements carefully. Check any boxes that apply to you to certify your eligibility for disenrollment.
6. Sign and date the form at the bottom. If someone else is signing on your behalf, ensure they provide their information as well.
7. 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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