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Get Disenrollment 2019-2024

L notify you of your effective date after we get this form from you. Instead of sending a disenrollment request to SilverScript Choice (PDP) you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, to disenroll by telephone. TTY users should call 1877-486-2048. Last Name First Name Middle Initial Mr. Mrs. Miss Ms. Member ID Birth Date Sex M F Home Phone Number ( ) By completing this disenrollment request, I agree to the following: SilverScript Ch.

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