Disenrollment Form for Medicare Plans
This disenrollment form is required for members of Humana plans who wish to cancel their membership. Carefully read the instructions and complete the form to ensure proper processing. Submitting this form will help you avoid potential penalties related to your Medicare coverage.
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How do I fill this out?
To fill out this disenrollment form correctly, begin by providing your Humana Member ID and the type of plan you're disenrolling from. Next, complete your personal details, including your name and contact information. Ensure all sections are filled out accurately before signing the form.
How to fill out the Disenrollment Form for Medicare Plans?
1
Read the instructions carefully.
2
Fill in your personal information.
3
Select the type of plan to disenroll from.
4
Sign and date the form.
5
Return the completed form as instructed.
Who needs the Disenrollment Form for Medicare Plans?
1
Individuals looking to switch Medicare plans may need this form.
2
Current members of Humana who want to disenroll require this form.
3
Individuals who want to avoid late enrollment penalties should use this form.
4
Authorized representatives who manage a member's Medicare plan may need this form.
5
Anyone needing to document disenrollment for personal records should complete this form.
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What are the instructions for submitting this form?
After properly completing the disenrollment form, you can submit it via mail to Humana’s Disenrollment Department at P.O. Box 14168, Lexington, KY 40512-4168. Alternatively, you may fax your completed form to 1-800-633-8188. It’s essential to keep a copy of the submitted form for your own records.
What are the important dates for this form in 2024 and 2025?
It is important to check the deadlines for disenrollment for the years 2024 and 2025, as they may vary based on specific annual enrollment periods for Medicare. Typically, significant dates revolve around the Medicare Annual Enrollment period, which occurs from mid-October to early December for changes for the following year.
What is the purpose of this form?
The disenrollment form is essential for members wishing to cancel their current Medicare plan with Humana. It is designed to ensure that the enrollment changes are processed officially and recorded appropriately. Submitting this form helps prevent any issues related to future Medicare coverage and potential penalties related to timely disenrollment.
Tell me about this form and its components and fields line-by-line.
- 1. Humana Member ID: Unique identification number for your Humana membership.
- 2. Plan Type: Selection of the Medicare plan you wish to disenroll from.
- 3. Member Name: Your full name as associated with the Humana plan.
- 4. Signature: Your signature to authorize the disenrollment.
- 5. Phone Number: Contact number for communication regarding your request.
What happens if I fail to submit this form?
Failure to submit the disenrollment form can lead to complications in your Medicare coverage. You may remain enrolled in your current plan and face potential late enrollment penalties in the future.
- Continuation of Coverage: You may be stuck in your current plan without the ability to change.
- Late Enrollment Penalty: You might incur penalties if you attempt to enroll later without proper documentation.
- Lack of Confirmation: You will not receive confirmation of disenrollment, leading to uncertainties in coverage.
How do I know when to use this form?
- 1. Transitioning to Another Plan: Use this form if you are switching to a different Medicare plan.
- 2. Avoiding Late Fees: Submit it promptly to prevent late enrollment penalties.
- 3. Formal Documentation of Disenrollment: Keep a record by completing and submitting this form.
Frequently Asked Questions
What is the purpose of the disenrollment form?
The form allows members to officially cancel their membership in Humana plans.
How do I fill out the disenrollment form?
Ensure to fill in your personal details, select your plan type, and sign the document.
Can I edit the PDF form on PrintFriendly?
Yes, you can use our tools to make changes directly to the PDF document.
Do I need to provide a reason for disenrollment?
No, the form does not require a reason for your disenrollment.
How will I know my disenrollment is processed?
You will receive a notification from Humana confirming your disenrollment.
Is there a deadline to submit this form?
Yes, ensure to submit it by the required deadlines to avoid penalties.
What happens if I don't complete this form?
You may face difficulties in changing plans or incur late fees.
Where can I submit my completed form?
Submit it by mail, fax, or the designated online submission platform.
Can I save my edits on PrintFriendly?
You can download the edited document to your device.
What if I need assistance with this form?
Reach out to Humana's customer service for any inquiries.
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