Can I disenroll outside enrollment periods?

Disenrollment eligibility depends on federal and CMS enrollment rules and whether you qualify for a Special Enrollment Period. Review plan materials or CMS guidance for qualifying events; administrative disenrollment for reasons like duplicate coverage is processed case-by-case.

Who can sign on behalf of a member?

A person with documented authority, such as a durable power of attorney or legal guardian, may sign. Provide supporting documentation with the form to avoid verification delays or rejection of the request.

Are electronic signatures accepted?

Electronic signatures are accepted if they meet ESIGN/UETA validity criteria: signer intent, consent to use electronic records, reliable attribution, and reproducible retention. Consumer-facing disclosures may be required.

What happens after I submit the form?

The plan verifies identity and authority, determines the effective date, updates enrollment records, and issues a confirmation to the member. Processing time depends on completeness of the submission and plan operational queues.

Do I need a notary or witness?

Most disenrollment forms do not require notarization or witnesses. If a representative signs or state-specific rules apply, the plan will request notarization or witness documentation as needed.

How long should I keep a copy?

Retain the signed form and supporting documents for at least three years and follow HIPAA six-year requirements for PHI; longer retention may be required by state law or plan policy.

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Amerivantage Select HMO Individual Disenrollment Form

Amerivantage Select HMO Individual Disenrollment Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Amerivantage Select (HMO) Individual Disenrollment Form 2017

Mail the completed form to the address below:

Amerigroup

P.O. Box 659403

San Antonio, TX 78265-9714

Or fax the completed form to: 1-800-833-8554

If you request disenrollment, you must continue to get all medical care from Amerivantage Select (HMO) until the effective date of disenrollment. Contact us at 1-866-805-4589 (TTY users should call 711) to verify your disenrollment before you seek medical services outside of Amerivantage Select (HMO)’s network. We are open 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. We will notify you of your disenrollment effective date after we get this form from you.

Please contact Amerivantage Select (HMO) if you need information in another language or format (Large Print, Audio or Braille).

Last name

First name

Middle initial

Title

Mr. Ms. Mrs. Miss

Member ID

Birth date

Sex

M F

Home phone number

Permanent residence street address

City

State

Zip code

Typically, you may disenroll from a Medicare Advantage plan only during the annual election period from October 15 through December 7 of each year or during the Medicare Advantage disenrollment period from January 1 through February 14 of each year. There are exceptions that may allow you to disenroll from a Medicare Advantage plan outside of these periods.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an election period.

It is annual election period (AEP) October 15 through December 7. I have other creditable coverage (such as member of Tricare/VA or want to obtain VA benefits).

I am enrolling or currently enrolled in an Employer Group Health Program (EGHP).

Effective date of EGHP Plan:

I get extra help paying for Medicare prescription drug coverage (Low-Income Subsidy). I have both Medicare and Medicaid or my state helps pay for my Medicare premiums. I no longer qualify for extra help paying for my Medicare prescription drugs.

I stopped receiving extra help on (insert date):

I am making a permanent move outside of the service area.

Date of move:

I am moving into, live in, or recently moved out of a Long-Term-Care Facility (for example, a nursing home).

I moved/will move into/out of the facility on (insert date):

I am joining a Program of All-Inclusive Care for the Elderly (PACE) program.

On (insert date):

I am joining employer or union coverage on (insert date).

I am disenrolling from Medicare Advantage during the disenrollment period January 1 through February 14. I am disenrolling from Medicare Advantage during the first 12 months after my Initial Election Period when I turned 65. Other

If none of these statements apply to you or you’re not sure, please contact Amerivantage Select (HMO) at 1-866-805-4589 (TTY users should call 711) to see if you are eligible to disenroll. We are open 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30.

Please carefully read and complete the following information before signing and dating this disenrollment form: If I have enrolled in another Medicare Advantage or Medicare prescription drug plan, I understand Medicare will cancel my current membership in Amerivantage Select (HMO) on the effective date of that new enrollment. I understand that I might not be able to enroll in another plan at this time. I also understand that if I am disenrolling from my Medicare prescription drug coverage and want Medicare prescription drug coverage in the future, I may have to pay a higher premium for this coverage.

I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the state where the individual resides) on this disenrollment form means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under state law to complete this disenrollment and 2) documentation of this authority is available upon request by Amerivantage Select (HMO) or by Medicare.

Applicant Signature or Authorized Representative as described above:*

Today’s date:

*If you are the Authorized Representative, you must sign above and provide the following information:

Authorized Representative name

Phone number

Relationship to enrollee

Street address

City

State

ZIP code

Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-805-4589 (TTY: 711)

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-805-4589 (TTY: 711).

What the Amerivantage Select HMO Individual Disenrollment Form Is

The Amerivantage Select HMO Individual Disenrollment Form is a member-facing document used to terminate enrollment in the Amerivantage Select HMO plan for a single enrollee. It captures identifying details, the requested effective date, reason for disenrollment and required signatures. The form may be submitted in paper or electronically and must meet applicable privacy and e-signature rules (ESIGN, UETA, HIPAA) when handled digitally.

Why this disenrollment form matters

A correctly completed disenrollment form preserves continuity of care, prevents billing surprises, and documents the member’s intent for plan termination. Accurate submissions reduce processing delays and ensure that Medicare and other payers update coverage records promptly.

Who typically completes this form

Primary users include enrolled members requesting plan exit, authorized representatives completing forms on a member’s behalf, and plan or broker staff who intake disenrollment requests.

Enrolled member submitting their own disenrollment request.
Authorized representative with documented power of attorney or written consent.
Plan or broker staff handling intake and routing to enrollment operations.

Third parties such as caregivers or legal representatives must provide documentation of authority; broker or plan intake staff should confirm identity before processing.

Step-by-step: how to complete the disenrollment form

Follow these sequential steps to prepare a clean, processable disenrollment request.

01

Collect ID: Confirm member name and Medicare/member ID.
02

Set effective date: Enter MM/DD/YYYY and verify eligibility window.
03

Attach authorization: Include POA or written consent if signed by representative.
04

Sign and submit: Obtain signature, then route to plan enrollment operations.

How the submission and processing flow works

This overview explains typical routing from intake through enrollment office processing and member notification.

Intake: Form received by broker, plan, or member services team.
Verification: ID, member number and authority documents are validated.
Processing: Enrollment team updates records and calculates effective date.
Confirmation: Member receives written confirmation of disenrollment outcome.

Configuring an electronic workflow for disenrollments

Key workflow settings help ensure secure intake, identity verification and auditability when using an e-submission process.

Field	Configuration
Member ID field	Required; validate format server-side
Signature field	Require signer authentication (email or code)
Attachment field	Allow uploads for POA or ID docs
Confirmation copy	Auto-email signed PDF to member

Technical and format considerations for electronic filing

Ensure the chosen system can export a complete audit trail and retain records to meet HIPAA and ESIGN/UETA requirements.

File formats: Accept PDF, DOCX; prefer flattened signed PDF.
Authentication: Email + access code or multi-factor recommended.
Integrations: Connectors to enrollee databases reduce manual errors.

Security and compliance checkpoints

Transport encryption: TLS 1.2/1.3 encrypted transit

Data at rest: AES-256 encrypted storage

Audit trail: Timestamped event history

HIPAA support: BAA available where required

ESIGN / UETA: Compliant for electronic records

21 CFR Part 11: Supported for regulated workflows

Potential consequences of incorrect or late disenrollment

Coverage gap: Unintended lapse or overlap in benefits

Billing errors: Continued premium charges until processed

Claims denials: Services billed to a terminated plan

Appeal workload: Increased administrative appeals and reviews

Authority disputes: Third-party signatures challenged without POA

Privacy risk: Improper PHI handling may breach HIPAA

Frequent errors to avoid

Using an incorrect or incomplete member ID that prevents matching to the plan record and delays processing.
Missing or unsigned authorization when a representative signs, which can lead to rejection and re-submission requests.
Entering an effective date outside allowable enrollment periods or failing to check Medicare enrollment rules for SEP eligibility.
Submitting attachments in unsupported file formats or without clear labeling, causing manual intake work and slower turnaround.

Representative eSignature vendor comparison for form workflows

Compare starting pricing and essential capabilities to select an eSignature platform that supports HIPAA, bulk sending, and audit trails for disenrollment forms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions about disenrollment and this form

Answers to common questions about timing, signature authority, electronic submissions and recordkeeping for Amerivantage Select HMO disenrollments.

Need help? Contact support

Can I disenroll outside enrollment periods?
Disenrollment eligibility depends on federal and CMS enrollment rules and whether you qualify for a Special Enrollment Period. Review plan materials or CMS guidance for qualifying events; administrative disenrollment for reasons like duplicate coverage is processed case-by-case.
Who can sign on behalf of a member?
A person with documented authority, such as a durable power of attorney or legal guardian, may sign. Provide supporting documentation with the form to avoid verification delays or rejection of the request.
Are electronic signatures accepted?
Electronic signatures are accepted if they meet ESIGN/UETA validity criteria: signer intent, consent to use electronic records, reliable attribution, and reproducible retention. Consumer-facing disclosures may be required.
What happens after I submit the form?
The plan verifies identity and authority, determines the effective date, updates enrollment records, and issues a confirmation to the member. Processing time depends on completeness of the submission and plan operational queues.
Do I need a notary or witness?
Most disenrollment forms do not require notarization or witnesses. If a representative signs or state-specific rules apply, the plan will request notarization or witness documentation as needed.
How long should I keep a copy?
Retain the signed form and supporting documents for at least three years and follow HIPAA six-year requirements for PHI; longer retention may be required by state law or plan policy.

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