Disenrollment Form

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:

Fax: 1-888-548-0098

You can also mail the completed form to:
Enrollment Department
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 Freedom Health to Original Medicare.

Until your disenrollment date, you must keep using Freedom Health’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 Freedom Health’s network.

If you need any help, please call us at 1-800-401-2740. TTY users should call 711. We are open from October 1 to February 14, from 8 a.m. to 8 p.m. 7 days a week and from February 15 to September 30, from 8 a.m. to 8 p.m. Monday through Friday.

Last Updated: 10/01/2016