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This form must be used by MI Choice waiver agencies to notify local Michigan ... Human Services (MD HHS) offices of MI Choice participant disenrollment dates, ...
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What is MI CHOICE WAIVER DISENROLLMENT NOTIFICATION Form?

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Mi choice waiver disenrollment is the process of voluntarily exiting the Mi Choice Waiver program.
Participants who no longer wish to remain in the Mi Choice Waiver program are required to file for disenrollment.
To fill out the Mi Choice Waiver disenrollment form, participants must provide their personal information and reason for disenrollment.
The purpose of Mi Choice Waiver disenrollment is to allow participants to voluntarily exit the program if they no longer wish to participate.
Participants must report their personal information, reason for disenrollment, and any additional required documentation.
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