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Disenrollment
2025
When can you end your membership in our plan?
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period (AEP) and during the Medicare Advantage Open Enrollment Period (MA OEP). In certain situations, you may also be eligible to leave the plan at other times of the year.
You can disenroll by:
- Completing the Disenrollment Form or requesting the Disenrollment form from Imperial Health Plan’s Member Service Department at 1-800-838-8271, (TTY: 711). Once received, you can fax it to 1-626-380-9066 or mail it to PO BOX 60874, Pasadena, CA 91116.
- Write a letter to the plan requesting to disenroll via fax to 1-626-380-9066 or mail it to PO BOX 60874, Pasadena, CA 91116.
- Enroll in another plan (during a valid enrollment period)
- Call 1-800-MEDICARE and request to disenroll
Disenrollment Form
- Disenrollment Form – English [PDF]
- Disenrollment Form – Spanish [PDF]
- Disenrollment Form – Chinese [PDF]
- Disenrollment Eligibility Attestation – English [PDF]
- Disenrollment Eligibility Attestation – Spanish [ PDF]
2024
When can you end your membership in our plan?
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period and during the annual Medicare Advantage Disenrollment Period. In certain situations, you may also be eligible to leave the plan at other times of the year.
You can disenroll by:
- Completing the Disenrollment Form or requesting the Disenrollment form from Imperial Health Plan’s Member Service Department at 1-800-838-8271, (TTY: 711). Once received, you can fax it to 1-626-380-9066 or mail it to PO BOX 60874, Pasadena, CA 91116.
- Write a letter to the plan requesting to disenroll via fax to 1-626-380-9066 or mail it to PO BOX 60874, Pasadena, CA 91116.
- Enroll in another plan (during a valid enrollment period)
- Call 1-800-MEDICARE and request to disenroll
Disenrollment Form
- Disenrollment Form – English [PDF]
- Disenrollment Form – Spanish [PDF]
- Disenrollment Form – Chinese [PDF]
- Disenrollment Eligibility Attestation – English [PDF]
- Disenrollment Eligibility Attestation – Spanish [ PDF]
To read PDFs, you will need Adobe Acrobat Reader. You can download here.
Member service hours:
April 1 – September 30 8:00 A.M. – 8:00 P.M. PST
Monday – Friday (except holidays)
October 1 – March 31 8:00 A.M. – 8:00 P.M. PST
Monday – Sunday (except holidays)
ADDRESS
Imperial Health Plan of California, Inc.
PO BOX 60874
Pasadena, CA 91116
PHONE
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