IMPORTANT! ACTION REQUIRED! AARP MEDICARE SUPPLEMENT ...
IMPORTANT! ACTION REQUIRED! AARP MEDICARE SUPPLEMENT ? TERMINATION OF PLAN
IMPORTANT! You will NOT be automatically disenrolled from your current Medicare Supplement Plan when your enrollment into the new City of Houston plan offerings effective on January 1,2021.
You MUST call or provide a written request to disenroll. City of Houston is NOT able to do this on your behalf.
If you do not disenroll from the AARP Medicare Supplement plan effective 12/31/2020, you will be billed directly for 100% of your Medicare Supplement Insurance policy premium.
1. Request to disenroll by calling the following number: Toll-Free Number: 1-800-545-1797 Choose Option #1 when prompted Request to terminate your coverage effective 12/31/2020 If you have a spouse in the plan, please have them present when calling
-OR-
2. Complete the bottom of this form and mail back to the address listed below.
REQUEST TO TERMINATE COVERAGE
Please terminate my coverage under the AARP Medicare Supplement Plan effective 12/31/2020
MEMBER ID # (from ID card): _________________________________________________
NAME (as it appears on your AARP Medicare Supplement ID):
____________________________________________________________________________
SIGNATURE:
DATE:
_____________________________________
______________________________
SPOUSE NAME (if applicable) _____________________________________________________________________________
SPOUSE SIGNATURE: (if applicable) _______________________________________
DATE: ________________________________
MAIL THIS FORM TO: UnitedHealthcare PO Box 30607
Salt Lake City, UT 84130-0607
AARP Medicare Supplement Insurance Plans are insured by UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents).
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