Employee Disenrollment Form

Employee Disenrollment Form

Welcome to the RMHP Online Employee Disenrollment Form.  In accordance with Colorado law, employers must notify RMHP of disenrolling employees or their covered dependents by the end of the month you wish their coverage to end. If RMHP is not notified of a disenrollment date that you wish the employee's coverage to end, you are required to pay premium, and the employee will remain covered until we receive a disenrollment notice. Retroactive disenrollment is not allowed.

Employers can electronically submit notice of employee disenrollment by completing and submitting the Electronic Disenrollment Notification below.

Note: If continuation of coverage entitlement applies (COBRA or Colorado Continuation of Coverage), please complete the COBRA/Continuation of Coverage section at the end of this form. RMHP will send Continuation of Coverage notification to the disenrolled employee or dependent.

 

Employee Disenrollment Form

In accordance with Colorado law, employers must notify RMHP of disenrolling employees or their covered dependents by the end of the month in which coverage is to end. If RMHP is not notified prior to the date the employer will be required to pay premium, and the employee will remain covered until we receive a disenrollment notice. Retroactive disenrollment is not allowed.

Employers can electronically submit notice of employee disenrollment by completing and submitting the Electronic Disenrollment Notification below.

Note: If continuation of coverage entitlement applies (COBRA or Colorado Continuation of Coverage), please complete the COBRA/Continuation of Coverage section at the end of this form. RMHP will send Continuation of Coverage notification to the disenrolled employee or dependent.

Required Information

Subscriber Information

Please complete for Disenrollment from Plan

Disenroll Coverage For:
Please cancel the coverage indicated above for the following reason(s):
Eligible for Coverage under Spouse or other Plan
Are any Dependent Children disenrolling from this Plan subject to a court order for Health Coverage?
Would you also like to submit a COBRA/Colorado Continuation of Coverage Event?

Employer or Broker Electronic Signature: