Foundational Community Supports
Complete this form if you would like to disenroll from the Foundational Community Supports
supportive housing and/or supported employment program. Please include your mailing
address so we may send you a confirmation letter. Once finished, email your completed form
to us at FCSTPA@amerigroup.com, fax it to 844-470-8859, or mail it to:
Amerigroup Washington, Inc.
705 5th Ave. S., Suite 300
Seattle, WA 98104
*Indicates a required field
*Date of birth:
*City, State ZIP:
*Choose the service(s) you’d like to disenroll from: Supportive housing Supported employment
Tell us why you’d like to disenroll:
By signing this form, you give Amerigroup Washington, Inc. the right to disenroll you from the
Foundational Community Supports service(s) checked above.
Enrollee signature: _________________________________ Date: _________________
Need help filing out this form? Call the Foundational Community Supports program at
844-451-2828 (TTY 711) Monday through Friday, 8 a.m. to 5 p.m. Pacific time.
Need this form in another language? Just call Member Services at 800-600-4441 (TTY 711)
Monday through Friday, 8 a.m. to 5 p.m. Pacific time. We’re here to help.