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Medicare Part D
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Open Enrollment Changes to Existing Coverage Special Enrollments Open Enrollment COBRA CHIP Enrollment Guidelines Membership at a Glance Member Resource Center - Widget Billing Forms Rx Center Tools and Resources Health & Wellness Newsletters Contact Us Health Care Reform for Employers
Member Cancellation
Section 2
- Check the box that indicates the reason for your cancellation.
- Complete the Date of Event box
Section 7
- If the subscriber is no longer employed, the Remitting Agent may sign the enrollment form on behalf of the employee
- If the subscriber is employed, but elects to cancel the coverage, the employee must sign the enrollment form.
Fax completed Group Enrollment forms to:
1-802-371-3329