Fillable Disenrollment Form Complete this form if you would

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Disenrollment Form Complete this form if you would

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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Foundational Community Supports
Disenrollment Form
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:
FCS TPA
Amerigroup Washington, Inc.
705 5th Ave. S., Suite 300
Seattle, WA 98104
*Indicates a required field
Enrollee information
*Date:
*First name:
*Date of birth:
*Street address:
ProviderOne #:
*Last name:
Phone number:
*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.
MF-WA-0107-20 myamerigroup.com/washington-fcs
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Completed 28 April 2021

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