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Medicare Advantage Disenrollment Form (Form D) 2021
51-0556Use this form to disenroll from a Medicare Advantage plan.
FormUMP (Regence) Authorization to Disclose Protected Health Information form
This form directs the Uniform Medical Plan's (UMP) administrator, Regence, to communicate with you about your personal health information (PHI).
FormUMP (WSRxS) Authorization for release of information
This form directs Washington State Rx Services (WSRxS) to communicate with you about your personal health information at the address you select. This form does not apply to your health care provider. You must give your provider separate, specific instruction about what health information they may share and with whom.
FormUMP (WSRxS) disclosure directive form
This form directs Washington State RX Services (WSRxS) to communicate with you about your personal health information at the address you select.
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