Disenrollment Form

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

Please select the state you live in:

Please select the Plan: *

Premier Care (HMO-POS I-SNP) - $0.00 per month

Senior Care (HMO I-SNP) - $24.60 per month

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First Name

Last Name

Middle Initial

Birth Date

Gender *
Male Female

Home Phone Number

Member ID

Medicare Number

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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 LifeWork Advantage 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 (Type your full name)

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.
2) Documentation of this authority is available upon request by LifeWork Advantage or by Medicare.

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Authorized Representative Information

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

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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.

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility) on

I am joining a PACE program on

Date of joining:

I am joining employer or union coverage on

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan on

Insert election period statements.

If none of these statements applies to you or you're not sure, please contact LifeWork Advantage at 1-844-854-6883 (TTY users should call 711) to see if you are eligible to disenroll. We are open Monday – Friday, 8:00 AM – 8:00 PM.

Disenrollment Form

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

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Authorized Representative Information

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

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