Medicare Advantage Disenrollment Form (Form D) 2021

51-0556

Use this form to disenroll from a Medicare Advantage plan.

Form

UMP (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).

Form

UMP (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.

Form

UMP (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.

Form