TotalCare (HMO D-SNP) Disenrollment Form

No one can make you stay in our plan if you don’t want to.

• You have the right to get most of your health care services through Original Medicare or another Medicare Advantage (MA) plan.
• You can get your Medicare Part D drug benefits from a drug plan or from another MA plan.
• Refer to Chapter 10 of this Member Handbook:
  • For more information about when you can join a new MA or drug benefit plan.
  • For information about how you’ll get your Medi-Cal benefits if you leave our plan.

The TotalCare document listed below can be viewed or downloaded as a PDF. To view and print it, you must have Adobe Acrobat Reader.

Please send the completed form to:

Member Services
1600 Green Hills Rd., Suite 101
Scotts Valley, CA 95066

Or email: [email protected]
Or fax: 831 430-5682

Click image below to open PDF file: