To download and print a blank disenrollment form, click here.
Please submit the completed form with a readable signature and date via one of the following options:
You can also mail the completed form to:
P.O. Box 151108
Tampa, FL 33684
When should I fill out the disenrollment request form?
- You should fill out the form if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.
- You shouldn’t fill out the form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.
- You shouldn’t fill out the form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from Optimum HealthCare to Original Medicare.
Until your disenrollment date, you must keep using Optimum HealthCare’s doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of Optimum HealthCare’s network.
If you need any help, please call us at 1-866-245-5360. TTY users should call 711. From October 1 to March 31, we are open 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, 8 a.m. to 8 p.m. EST.