Can I use an electronic signature?

Yes. Electronic signatures are acceptable when they meet ESIGN and UETA requirements and any plan-specific authentication policies; ensure the platform preserves an auditable trail showing signer identity and timestamp.

When does disenrollment take effect?

Effective dates depend on the election period and plan processing timelines; requests during Annual Election Period or Open Enrollment follow standard CMS timing and may take several weeks to reflect.

What if my Medicare ID is wrong?

An incorrect Medicare Beneficiary ID prevents successful matching and will delay processing. Submit a corrected form with the exact MBI from your Medicare card to avoid rework.

Do I need a notary or witness?

Notarization or witnesses are generally not required for Medicare Advantage disenrollment forms; check plan instructions and state rules if any special authentication is requested.

How will I get confirmation?

Plans typically send written confirmation by mail or electronically after processing; retain your submitted copy and follow up if confirmation is not received within the expected window.

Can disenrollment be reversed?

Reversals depend on timing and election period rules; reversing a disenrollment often requires contacting the plan and may be subject to CMS enrollment rules and appeal processes.

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Kaiser Senior Advantage Disenrollment Form

Kaiser Senior Advantage Disenrollment Form

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Kaiser Permanente Senior Advantage (HMO), Kaiser Permanente Medicare Cost,
or Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan (HMO SNP)
DISENROLLMENT FORM

Northern California or Southern California Region

Each individual disenrolling will need to complete his/her own form. If you have any questions, please call us toll free at 1-800-443-0815 (TTY 1-800-777-1370 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m.

If you request disenrollment, you must continue to get all medical care from Kaiser Permanente, until the effective date of disenrollment. Please refer to your Evidence of Coverage for more details. Contact us to verify your disenrollment before you seek medical services outside of Kaiser Permanente’s network. We will notify you of your effective date of disenrollment in writing after we get this form from you.

When enrolled in the Kaiser Permanente Senior Advantage plan, you can only disenroll at certain times during the year unless you meet certain special circumstances. If you have questions about the times you may disenroll from our Plan, please call us at the number listed above.

PLEASE TYPE OR PRINT USING BLACK OR BLUE INK

KAISER PERMANENTE MEDICAL RECORD #

LAST NAME

FIRST NAME

MI

MAILING ADDRESS

MEDICARE #

CITY

STATE

ZIP

BIRTH DATE

SEX

M F

HOME PHONE NUMBER

PLEASE SELECT A DISENROLLMENT REASON BELOW

I have moved out of the Kaiser Permanente service area I have joined another health plan My employer group coverage has ended Other—Please explain

Please carefully read and complete the following information before signing and dating this disenrollment form.

If I have enrolled in another Medicare Health Plan or Medicare Prescription Drug Plan, I understand Medicare will cancel my current membership in Kaiser Permanente Senior Advantage, Kaiser Permanente Medicare Cost, or Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan 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.

For Kaiser Permanente Medicare Cost plan members only: If you want to return to Original Medicare (also known as the Medicare fee-for-service program), then you must complete this disenrollment form. We will notify you of the effective date of your disenrollment after we have received this form from you.

If you want to join another HMO immediately following termination from Kaiser Permanente Medicare Cost, then you do not need to complete this form. Once you enroll in another HMO, your current membership in Kaiser Permanente Medicare Cost will automatically be cancelled. However, please note that you can generally only choose other plans at certain times of the year. I understand that the Kaiser Permanente Medicare Cost plan is closed to new enrollment and I cannot re-enroll.

Disenrollment from the Kaiser Permanente Medicare Cost plan will be effective on the first day of the month after the month Kaiser Permanente receives the written request (unless you request a later date of disenrollment). For example, if you complete this form and submit it to Kaiser Permanente on April 30, the last day of the month, your disenrollment will be effective the next day, May 1. If you are requesting a later date, disenrollment cannot take place later than the third month after which you submit a completed disenrollment request to Kaiser Permanente. Therefore, if you submit this form on April 30, the latest disenrollment date possible would be July 1.

For Employer Group/Trust Fund members only: I understand that my disenrollment from Kaiser Permanente Senior Advantage or Medicare Cost may affect my employer group or trust fund coverage, and I must also contact my Group Benefits Office to complete the termination process.

For Federal Employees Health Benefit (FEHB) Program members only: The choice you make will not impact the benefits you receive through the FEHB Program. Coverage for the FEHB Program is described in your FEHB brochure. Your choice will affect the additional benefits you receive as a member of Kaiser Permanente Senior Advantage or Medicare Cost for Federal employees.

Your signature*

Date

*Or the signature of the person authorized to act on your behalf under the laws of the State where you live. 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 Kaiser Permanente or by Medicare.

If you are the authorized representative, you must provide the following information:

Name

Address

Phone number

Relationship to enrollee

Kaiser Permanente is a health plan with a Medicare contract.

This information is available in a different format by calling the number listed on the first page.

Return the top, signed white copy to:

Kaiser Permanente—Medicare Unit

P.O. Box 232400

San Diego, CA 92193

If required, send the middle pink copy to your employer group or union/trust fund.

Keep the bottom yellow copy for your records.

What the Kaiser Senior Advantage Disenrollment Form Is

The Kaiser Senior Advantage Disenrollment Form is a Medicare Advantage plan disenrollment notice used by members who want to terminate enrollment in a Kaiser Medicare Advantage plan and, where applicable, return to Original Medicare or enroll in a different Medicare plan. The form collects member identity, plan details, requested effective date, and signature. It documents the member's clear intent to end the Advantage plan and creates a record for the plan and Centers for Medicare & Medicaid Services (CMS) or other administering entity to process the request.

Why this form matters for beneficiaries and administrators

A properly completed disenrollment form establishes intent, defines the requested effective date, and triggers plan and CMS workflows so coverage changes occur with minimal delay and recordable proof of consent.

Step-by-step: Completing the disenrollment form

Follow these core steps to ensure the form is accepted and processed without delay.

01

Confirm eligibility: Verify your enrollment status and any applicable election period before submitting.
02

Fill member details: Enter full legal name, Medicare ID, and contact information accurately.
03

Select effective date: Choose the desired termination date per enrollment rules and deadlines.
04

Sign and submit: Sign, date, and send to the designated plan or CMS address.

How to set up an online disenrollment workflow

Configure a digital workflow that collects required fields, verifies identity, and routes submissions to the plan and CMS if applicable.

Field	Configuration
Identity Field	Require Medicare ID and DOB for matching
Signature Field	Enable electronic signature with audit trail
Routing	Auto-send completed form to plan intake address
Record Retention	Archive signed copy in secure repository

Typical submission and processing path

Understand the sequence of actions after you submit a disenrollment request so you can track status and anticipate next steps.

Submit form: Member signs and sends to Kaiser or designated agent.
Plan intake: Plan verifies identity and membership details.
Plan processes request: Plan updates enrollment and notifies CMS if applicable.
Confirmation issued: Member receives written confirmation of effective date.

Digital submission options and system needs

Electronic submission saves time but must meet identity and record requirements for healthcare and Medicare records.

Document formats: PDF or DOCX accepted
Authentication: Email or multi-factor
Integrations: Supports EHR and archive systems

Essential elements of a professional disenrollment form

A clear, complete form protects member rights and speeds administrative processing.

Member identity

Full legal name, Medicare Beneficiary ID, and date of birth to enable reliable matching to plan and CMS records.

Plan identification

Exact Kaiser Senior Advantage plan name and plan number so administrators can locate the member's enrollment without ambiguity.

Requested effective date

Explicit MM/DD/YYYY effective date; must align with allowable election periods to avoid coverage overlap or gaps.

Reason (optional)

Optional field for member to note reason; recorded for quality metrics but not required for processing.

Signature and date

Handwritten or compliant electronic signature with date to demonstrate intent and consent under ESIGN/UETA.

Submission instructions

Clear routing details: plan mailing address, fax, secure upload, or CMS submission pathway for timely handling.

Required information checklist

Member name: Full legal name

Medicare ID: MBI as shown on card

Birth date: MM/DD/YYYY format

Plan ID: Kaiser plan name/number

Effective date: MM/DD/YYYY

Signature: Signed and dated

Key timelines and enrollment windows to know

Timing rules determine when disenrollment takes effect and whether you can return to Original Medicare or select another plan.

Annual Election Period:

Oct 15–Dec 7 for most Medicare plan changes

Medicare Advantage OEP:

Jan 1–Mar 31 for one-time changes after January 1

Special Enrollment Periods:

Available for qualifying life events; timing varies by event

Plan termination notices:

Plans must notify members in advance of contract changes

Processing time:

Allow several weeks for plan and CMS updates

Consequences of incomplete or incorrect forms

Delayed coverage: Processing delays

Coverage gap: Potential uninsured period

Claim denials: Services may be billed incorrectly

Loss of options: Missed election windows

Premium obligations: Outstanding premiums may still apply

Appeals needed: Reversal may require formal appeal

Common mistakes that cause processing delays

Using a name variant instead of the exact name on the Medicare card, causing identity mismatches and verification failures.
Entering an effective date outside allowed election periods, which can void the request or change the outcome unexpectedly.
Omitting or mistyping the Medicare Beneficiary ID (MBI), which prevents plan staff from locating the member record.
Failing to sign or date the form, or using initials where a full signature is required, resulting in rejected submissions.

Tips to complete and submit the form accurately

Adopt these practices to minimize review cycles and secure an accurate effective date.

Verify identity details against your Medicare card

Before submission, compare the form fields to your Medicare card and government ID; matching exactly reduces verification delays and prevents mismatches that require rework by plan staff.

Confirm eligible election period

Check whether your requested effective date falls within the Annual Election Period, Medicare Advantage Open Enrollment, or an applicable Special Enrollment Period to ensure timely processing.

Use an auditable signature method

If submitting electronically, choose a platform that provides an audit trail capturing signer identity, timestamp, and IP or authentication method for legal and compliance purposes.

Retain copies and follow up

Keep a signed copy and note submission dates; follow up with the plan if confirmation is not received within the expected processing window.

eSignature platform comparison relevant to form submission

Comparison of common eSignature providers on core items useful when digitizing disenrollment forms; signNow is listed first per platform overview rules.

	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 plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs — common questions about the disenrollment form

Answers to frequent issues encountered when completing or submitting a Kaiser Senior Advantage disenrollment request.

Need help? Contact support

Can I use an electronic signature?
Yes. Electronic signatures are acceptable when they meet ESIGN and UETA requirements and any plan-specific authentication policies; ensure the platform preserves an auditable trail showing signer identity and timestamp.
When does disenrollment take effect?
Effective dates depend on the election period and plan processing timelines; requests during Annual Election Period or Open Enrollment follow standard CMS timing and may take several weeks to reflect.
What if my Medicare ID is wrong?
An incorrect Medicare Beneficiary ID prevents successful matching and will delay processing. Submit a corrected form with the exact MBI from your Medicare card to avoid rework.
Do I need a notary or witness?
Notarization or witnesses are generally not required for Medicare Advantage disenrollment forms; check plan instructions and state rules if any special authentication is requested.
How will I get confirmation?
Plans typically send written confirmation by mail or electronically after processing; retain your submitted copy and follow up if confirmation is not received within the expected window.
Can disenrollment be reversed?
Reversals depend on timing and election period rules; reversing a disenrollment often requires contacting the plan and may be subject to CMS enrollment rules and appeal processes.

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