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Get the free Disenrollment Form for MassHealth-Only Members (2024)

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Commonwealth Care Alliance Enrollment Department 30 Winter Street Boston, MA 02108Disenrollment Form If you request disenrollment, you must continue to get all medical care from CCA Senior Care Options
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How to fill out disenrollment form for masshealth-only

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How to fill out disenrollment form for masshealth-only

01
Obtain the disenrollment form for MassHealth-only from the MassHealth website or request a copy from a MassHealth representative.
02
Fill out all the required information on the form, including your personal details, MassHealth identification number, and reason for disenrollment.
03
Make sure to sign and date the form before submitting it.
04
Submit the completed disenrollment form to MassHealth by mail, fax, or in person at a MassHealth enrollment center.

Who needs disenrollment form for masshealth-only?

01
Individuals who are currently enrolled in MassHealth-only and wish to disenroll from the program.
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The disenrollment form for MassHealth-only is a document that allows individuals to voluntarily terminate their enrollment in the MassHealth program, which provides health insurance coverage for eligible residents of Massachusetts.
Individuals who wish to end their participation in the MassHealth program, including beneficiaries who no longer meet eligibility criteria or who choose to switch to a different insurance plan, are required to file the disenrollment form.
To fill out the disenrollment form for MassHealth-only, individuals should complete all required fields, including personal identification information, reason for disenrollment, and date of request, then submit the form to the appropriate MassHealth office.
The purpose of the disenrollment form for MassHealth-only is to formally notify the program of an individual's decision to terminate their health coverage and ensure that the process is documented and executed according to regulations.
The disenrollment form must report information such as the individual's name, address, MassHealth ID number, reason for disenrollment, effective date of disenrollment, and any relevant contact details.
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