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Medicare Plan Disenrollment Form (form D) 2025

Use this form to disenroll from Medicare Advantage.

51-0556
Form

Free or low-cost health care
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- I help others apply for & access Apple Health
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- Quick links
- Contact Apple Health (Medicaid)
- News
Employee & retiree benefits
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  - Learn how & why to defer
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  - Get help
- PEBB Continuation Coverage
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  - Explore costs
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    - For newly eligible members
    - Verify & enroll my dependents
  - For survivors
  - Manage benefits
  - Get help
- SEBB Continuation Coverage
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  - Explore costs
  - Determine eligibility
  - Learn how to enroll
    - For newly eligible members
    - Verify & enroll my dependents
  - For survivors
  - Manage benefits
  - Get help
- Quick links
- Contact us
- PEBB news
- SEBB news
Billers, providers & partners
- Prior authorization, claims & billing
  - Getting started
  - Submit prior authorization (PA)
    - Step-by-step guide for prior authorization (PA)
    - Pharmacy prior authorization
  - Submit claims
    - Provider billing guides & fee schedules
    - Hospital rates & reimbursement
- Program information for providers
- Become an Apple Health provider
  - Learn how to enroll
  - What's next
    - Track my application
    - Find next steps for new Medicaid providers
  - For existing medicaid providers
    - Update my provider information
    - Revalidation
- Learn ProviderOne
  - Getting started
    - How do I access ProviderOne?
  - Training materials
- Quick links
- Contact us
- News
About HCA
- Programs & initiatives
- Who we are
  - About us
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  - Health innovation
- Data & reports
- Other administrative activities
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  - Government transparency
    - Gender identity information
    - Public disclosure request
  - Community services
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- News
  - Find out what's new
  - Follow HCA on social media
  - For the press
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- Contact HCA
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