Health Net Disenrollment Form – Fill Out and Use This PDF

HEALTH NET MEDICARE PROGRAMS

EMPLOYER GROUP DISENROLLMENT FORM

If you request disenrollment, you must continue to get all medical care from Health Net Medicare Programs until the effective date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of Health Net Medicare Program’s network. We will notify you of your effective date after we get this form from you.

Please fax this form to: Health Net Medicare Programs Enrollment Services (818) 337-7241, or mail to Health Net Medicare Programs Enrollment Services, P.O. Box 10420, Van Nuys, CA 91410.

Please carefully read and complete the following information before signing and dating this disenrollment form:

If I have enrolled in another Medicare Advantage or Medicare Prescription Drug Plan, I understand Medicare will cancel my current membership in Health Net Medicare Programs on the effective date of that new enrollment. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future, I may have to pay a higher premium for this coverage.

Your Signature*: ______________________________________________________ Date: ________________

*Or the signature of the person authorized to act on your behalf under the laws of the State where you live. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this disenrollment and 2) documentation of this authority is available upon request by Health Net Medicare Programs or by Medicare.

If you are the authorized representative, you must provide the following information:

Name: _________________________________________________________________________________________

Address: _________________________________________________________________________________________

Phone Number: (______) _______ - __________

Relationship to Enrollee __________________________________________________________________________

6021756 CA66520 (8/10)

Material ID # H0562_EG_2011_0043 Compliance Approved 09142010