I have carefully read and understand that:
1. My monthly premium will increase/decrease by adding/removing optional
supplemental dental coverage to/from my current plan.
2. The above stated premium amounts do not include any Medicare late enrollment
penalties for which I may be currently responsible.
3. My current premium payment method will remain the same.
Signature*: ______________________________ Date: _____________
*Or the signature of the person authorized to act on your behalf under the laws of the State where
you live. If signed by an authorized individual (as described above), this signature certifies that:
1) this person is authorized under State law to complete this disenrollment and 2) documentation
of this authority is available upon request by Johns Hopkins Advantage MD or by Medicare.
If you are the authorized representative, you must provide the following information:
Name : _________________________________
Phone Number: (_____) ______- __________________
Relationship to Enrollee ______________________________
Please mail or fax the completed form to Johns Hopkins Advantage MD P.O. Box 3538
Scranton, PA 18505, fax: 855-206-9203. If you have questions about this form or need more
information, please contact Customer Service at 1-877-293-5325 (TTY 711), Oct. 1 through
March 31 - Monday through Sunday, 8 a.m. to 8 p.m. and April 1 through Sept. 30 - Monday
through Friday, 8 a.m. to 8 p.m.
click to sign
click to edit