DISENROLLMENT FORM - California`s Valued Trust

Kaiser Permanente Senior Advantage (HMO), Kaiser Permanente Medicare Cost,
or Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan (HMO SNP)
DISENROLLMENT FORM
Northern California or Southern California Region
Each individual disenrolling will need to complete his/her own form. If you have any questions, please
call us toll free at 1-800-443-0815 (TTY 1-800-777-1370 for the hearing/speech impaired), seven days a
week, 8 a.m. to 8 p.m.
If you request disenrollment, you must continue to get all medical care from Kaiser Permanente,
until the effective date of disenrollment. Please refer to your Evidence of Coverage for more
details. Contact us to verify your disenrollment before you seek medical services outside of Kaiser
Permanente’s network. We will notify you of your effective date of disenrollment in writing after we
get this form from you.
When enrolled in the Kaiser Permanente Senior Advantage plan, you can only disenroll at certain times
during the year unless you meet certain special circumstances. If you have questions about the times you
may disenroll from our Plan, please call us at the number listed above.
PLEASE TYPE OR PRINT USING BLACK OR BLUE INK
KAISER PERMANENTE
LAST NAME
FIRST NAME
MEDICAL RECORD #
MI
MAILING ADDRESS
MEDICARE #
BIRTH DATE
CITY
Sex:
M
F
STATE
ZIP
HOME PHONE NUMBER
PLEASE SELECT A DISENROLLMENT REASON BELOW
I have moved out of the Kaiser Permanente service area
I have joined another health plan
My employer group coverage has ended
Other—Please explain
Please carefully read and complete the following information before signing and
dating this disenrollment form.
If I have enrolled in another Medicare Health Plan or Medicare Prescription Drug Plan, I understand
Medicare will cancel my current membership in Kaiser Permanente Senior Advantage, Kaiser Permanente
Medicare Cost, or Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan 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.
For Kaiser Permanente Medicare Cost plan members only: If you want to return to Original Medicare
(also known as the Medicare fee-for-service program), then you must complete this disenrollment form.
We will notify you of the effective date of your disenrollment after we have received this form from you.
WHITE—Kaiser Permanente
PINK—Employer group/union/trust fund
YELLOW—Keep for your records
Y0043_N004869 CMS Approved (05/16/2011)
SKU 60050607 CA
If you want to join another HMO immediately following termination from Kaiser Permanente Medicare
Cost, then you do not need to complete this form. Once you enroll in another HMO, your current membership in Kaiser Permanente Medicare Cost will automatically be cancelled. However, please note that
you can generally only choose other plans at certain times of the year. I understand that the Kaiser Permanente Medicare Cost plan is closed to new enrollment and I cannot re-enroll.
Disenrollment from the Kaiser Permanente Medicare Cost plan will be effective on the first day of the
month after the month Kaiser Permanente receives the written request (unless you request a later date
of disenrollment). For example, if you complete this form and submit it to Kaiser Permanente on April 30,
the last day of the month, your disenrollment will be effective the next day, May 1. If you are requesting
a later date, disenrollment cannot take place later than the third month after which you submit a completed disenrollment request to Kaiser Permanente. Therefore, if you submit this form on April 30, the
latest disenrollment date possible would be July 1.
For Employer Group/Trust Fund members only: I understand that my disenrollment from Kaiser Permanente Senior Advantage or Medicare Cost may affect my employer group or trust fund coverage, and I
must also contact my Group Benefits Office to complete the termination process.
For Federal Employees Health Benefit (FEHB) Program members only: The choice you make will not
impact the benefits you receive through the FEHB Program. Coverage for the FEHB Program is described
in your FEHB brochure. Your choice will affect the additional benefits you receive as a member of Kaiser
Permanente Senior Advantage or Medicare Cost for Federal employees.
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 Kaiser Permanente or by Medicare.
If you are the authorized representative, you must provide the following information:
Name
Address
Phone number
Relationship to enrollee
Kaiser Permanente is a health plan with a Medicare contract.
This information is available in a different format by calling the number listed on the first page.
Return the top, signed white copy to:
Kaiser Permanente—Medicare Unit
P.O. Box 232400
San Diego, CA 92193
If required, send the middle pink copy to your employer group or union/trust fund.
Keep the bottom yellow copy for your records.