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Plans underwritten by Rocky Mountain HMO (RM HMO) or Rocky Mountain Healthcare Options, Inc. (RICO) Disenrollment Form Complete this form using black ink only. MHP USE ONLY 1C Plan Group Mail Rec

How to fill out tba completemybenefits com form

How to Fill Out Employee Disenrollment Form:

1. Obtain the employee disenrollment form from your human resources department or employer.
2. Read the instructions carefully to understand the information required and any supporting documentation needed.
3. Begin by providing your personal information, such as your full name, employee identification number, and contact details.
4. Indicate the reason for disenrollment from the company's employee benefits program. This may include leaving the company, retirement, or changing employment status.
5. If applicable, provide the effective date of disenrollment or the date you want the changes to be implemented.
6. Review the options available for disenrollment, such as health insurance, dental coverage, retirement plans, and other benefits. Select the benefits from which you wish to disenroll.
7. If required, include any supporting documents or explanations necessary for the disenrollment process. For example, if you are leaving the company, you may need to submit a resignation letter or retirement notice.
8. Sign and date the form, indicating that the information provided is accurate and complete.
9. Make a copy of the completed form for your records before submitting it to the designated department or individual.

Who Needs Employee Disenrollment Form:

1. Employees who are leaving the company or changing employment status: If you are resigning, retiring, or switching jobs, you may need to complete an employee disenrollment form to discontinue your participation in the company's benefits program.
2. Employees who no longer wish to receive specific benefits: If you no longer want or need certain benefits offered by your employer, such as health insurance or retirement plans, you may need to fill out an employee disenrollment form to opt out of those benefits.
3. Employees who experience a change in eligibility: If your eligibility for certain benefits has changed due to factors like age, marital status, or dependent status, you may be required to complete an employee disenrollment form to update your enrollment status and discontinue or modify your benefits accordingly.

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