Medicare Member Disenrollment

Do you want to disenroll from your Wellcare By Allwell plan?  We’re sorry to see you go!

You can use the Disenrollment Form to disenroll from your Wellcare By Allwell plan.  Note that if you request disenrollment, you must continue to get all medical care from your plan until the effective date of disenrollment. Contact Us to verify your disenrollment before you seek medical services outside of our network. We will notify you of the effective date of your disenrollment from the plan following receipt of this form.

Instructions

You may type to complete the:

Disenrollment Form English - (PDF)

Disenrollment Form Spanish - (PDF)

To do so, download and complete the form on your computer.

Please mail or fax your completed form.

For more information on disenrollment, including your rights and responsibilities upon disenrollment, refer to the following chapters in your Evidence of Coverage: Chapter 10 on Disenrollment and Chapter 8 on Member Rights and Responsibilities

Medicare Member Disenrollment

Do you want to disenroll from your Ascension Complete plan?  We’re sorry to see you go!

You can use the Disenrollment Form to disenroll from your  Ascension Complete plan.  Note that if you request disenrollment, you must continue to get all medical care from your plan until the effective date of disenrollment. Contact Us to verify your disenrollment before you seek medical services outside of our network. We will notify you of the effective date of your disenrollment from the plan following receipt of this form.

Member Disenrollment Form

Are you a Ascension Complete member who would like to disenroll from your coverage plan? Use this form to request a disenrollment. If you request disenrollment, you must continue to get all medical care from your plan until the effective date of disenrollment. Contact us to verify your disenrollment before you seek medical services outside of our network. We will notify you of your effective date following receipt of this form. 

Note: To complete this form, you must have a valid disenrollment password.  To obtain a disenrollment password, please Contact Us. One of our helpful Member Services representatives will speak with you about disenrollment and provide you with your password.

For more information on disenrollment, including your rights and responsibilities upon disenrollment, refer to the following chapters in your Evidence of Coverage: Chapter 10 on Disenrollment and Chapter 8 on Member Rights and Responsibilities.