Disenrollment Form

Each member requesting to be disenrolled must complete their own form.

If you request disenrollment, you must continue to get all medical care from Wellcare By Fidelis Care until the effective

date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of Wellcare By

Fidelis Care's network. We will notify you of your effective date after we get this form from you.

If you have any questions, call Wellcare By Fidelis Care at the appropriate number below.

We are available 8:00 a.m. to 8:00 p.m. Member Services is available seven days per week between

October 1st and March 31st. For the period of April 1st to September 30th, Member Services is available

Monday through Friday, TTY users should call 711.

YOU MAY TYPE TO COMPLETE THIS FORM. YOU MAY ALSO PRINT IT AND FILL IT OUT, IN WHICH CASE PLEASE PRINT

YOUR RESPONSES USING BLACK OR BLUE INK. FILL CHECK BOXES IN WITH AN “X”.

Last Name ________________________________________________First Name ______________________________________ MI___

Wellcare By Fidelis Care Subscriber ID Number ____________________________________________________________________________________________

Medicare Number ________________________________________________________________________________________________________________________________

City __________________________________________________________________________ State _________________________________ Zip Code _________________________

Email Address _____________________________________________________________________________________________________________________________________

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 that Medicare will

cancel my current membership with Wellcare By Fidelis Care on the effective date of the new enrollment. I understand

that I may 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, due to a late enrollment penalty, for this coverage.

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Y0020_WCM_100845E_C Internal Approved 07252022 NA2CNCFRM00851E_0000

I understand that my signature (or the signature of the person I have authorized to make decisions on my behalf) on

this form means I have read and understand the contents of this form. If signed by an authorized representative, this

signature certifies that: this person is authorized under State law to complete this disenrollment, and documentation of

this authority is available upon request.

Signature*:

_____________________________________________________________________ Today’s 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 Wellcare By

Enrollment Period from January 1 through March 31 of each year.

There are exceptions which may allow you to disenroll outside of this period. If you have questions about the

times you may disenroll, please call Member Services for assistance.

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.

.

8:00 p.m. Member Services is available seven days per week between October 1st and March 31st. For the period

of April 1st to September 30th, Member Services is available Monday through Friday, TTY users should call 711.

Other _______________________________________________

such as qualified sign language interpreters and written information in other formats (large

print, audio, accessible electronic formats, other formats).

qualified interpreters and infor

Sección1557:Idioma de No Discriminación

Aviso de No Discriminación

sotros, tales como intérpretes calificados de lengua de

señas e información escrita en otros formatos (letra grande, audio, formatos electrónicos