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MEMBER RESOURCES

Disenrollment Form

If you request disenrollment, you must continue to get all medical care from Align Senior Care until the effective date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of Align Senior Care's network. We will notify you of your effective date after we get this form from you.

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Section 1

Patient Information

Section 2

Signature

Please carefully read and complete the following 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 Align Senior Care 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.

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.
2) Documentation of this authority is available upon request by Align Senior Care or by Medicare.

Section 3

Authorized Representative Information

If this form is signed by a legal representative (e.g., Power of Attorney, Legal Guardian), a copy of the supporting legal documentation (e.g., POA or guardianship papers) must be submitted to the plan for verification. If you have not previously submitted, please email the Enrollment Dept at: [email protected]

Please Note* HIPAA and Health Care Proxy forms do not provide authority to act on the member's behalf.

Section 4

Information to include on or with Disenrollment Form Attestation of Eligibility for an Election Period

Typically, you may disenroll from a Medicare Advantage plan only during the annual enrollment period October 15 through December 7 of each year or during the Medicare Advantage Open Enrollment Period January 1 through March 31 of each year.

There are exceptions that may allow you to disenroll from a Medicare Advantage Plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Election Period.

If none of these statements applies to you or you're not sure, please contact Align Senior Care at 1-844-788-8935 (TTY users should call 711) to see if you are eligible to disenroll. We are open Monday – Friday, 8:00 AM – 8:00 PM.

All information you provide here is strictly confidential, secure, and will only be used to process your disenrollment request.