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SSI New Jersey Department of Human Services NOTICE OF PROGRAM Disenrollment: Date: CWA / Board of Social Services (CP23 not sent to CWA if on SSI)DHS Regional Office, Office of Community Choice Options
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What is NOTICE OF PROGRAM DISENROLLMENT Form?

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The notice of program disenrollment is a form that must be submitted to inform a program that a participant is no longer participating in the program.
Participants who wish to disenroll from a program are required to file a notice of program disenrollment.
Participants can fill out the notice of program disenrollment form by providing their personal details, program information, and reasons for disenrollment.
The purpose of notice of program disenrollment is to officially notify the program of a participant's decision to disenroll.
The information that must be reported on the notice of program disenrollment includes participant's name, program name, disenrollment date, and reasons for disenrollment.
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