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Michigan Department of Health and Human Services MI CHOICE WAIVER DISENROLLMENT NOTIFICATION INSTRUCTIONS This form must be used by MI Choice waiver agencies to notify local Michigan Department of
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Obtain a copy of the mi choice waiver disenrollment form.
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Fill out the personal information section, including your name, address, and contact information.
03
Indicate the reason for disenrollment from mi choice waiver.
04
Provide any additional information or documentation required, such as medical records or supporting documents.
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Submit the completed form to the appropriate authority or agency responsible for handling mi choice waiver disenrollment.

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Anyone who wishes to disenroll from mi choice waiver program needs mi choice waiver disenrollment.
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Mi Choice waiver disenrollment is the process of ending participation in the Mi Choice waiver program.
Participants who wish to end their participation in the Mi Choice waiver program are required to file for disenrollment.
To fill out the Mi Choice waiver disenrollment, participants need to complete the disenrollment form provided by the program and submit it according to the instructions.
The purpose of Mi Choice waiver disenrollment is to allow participants to voluntarily end their participation in the program.
Participants must provide personal information, reasons for disenrollment, and any required documentation when filling out the Mi Choice waiver disenrollment form.
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