Date Name Address Address RE: Health Home Program Dear: The Health Care Authority will end your enrollment in the Health Home program as of (must be the 1st of This is because it was unsafe to provide Health the month and at least 10 days from the date of this letter). Home services at your home or the location of your choice. This letter only applies to your Health Home services. It does not affect how you receive any of your other current Medicare, Medicaid, or Washington Apple Health benefits. In order to receive Health Home services you must agree to participate and to develop a Health Action Plan with a Health Home care coordinator in a safe location of your choice. If you decide to participate in the Health Home program and you are still eligible, you may request to be reenrolled by calling our customer service line at . Sincerely, Health Home Lead
Date Name Address Address RE: Health Home Program Dear: The Health Care Authority will end your enrollment in the Health Home program as of (must be the 1st of the month and at least 10 days from the date of this letter). This is because it was unsafe to provide Health Home services at your home or the location of your choice. This letter only applies to your Health Home services. It does not affect how you receive any of your other current Medicare, Medicaid, or Washington Apple Health benefits. In order to receive Health Home services you must agree to participate and to develop a Health Action Plan with a Health Home care coordinator in a safe location of your choice. If you decide to participate in the Health Home program and you are still eligible, you may request to be reenrolled by calling our customer service line at . Sincerely, Health Home Lead
involuntary-disenrollment-sample-letter.docx