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Member Disenrollment

Use of this form is restricted to MHS members only. Use a separate form for each family. Care must be provided to the member for up to 30 calendar days following the disenrollment request submission to MHS, or until the change process is completed.

Provider Information

Member Information

(List all family members)

Member #1

Member #2

Member #3

Member #4

Member #5

Member #6

Reason for Request required *
The member(s) has been notified of the request for disenrollment: required *
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Last Updated: 02/08/2024