Your Rights Upon Disenrollment | Ascension Complete

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.


You may type to complete the:

Disenrollment Form English - (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

Your Rights Upon Disenrollment

Chapter 10 of your Evidence of Coverage includes information on the member’s and plan’s rights and responsibilities upon disenrollment. Visit the Plan Benefit Materials page to view your plan’s Evidence of Coverage.

We don't want to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.

If you have questions please, contact Member Services.