Español Medicare Plans Members Providers Agents & Brokers OTC Quick Links Member Login Disenrollment Form To download and print a blank disenrollment form, click here. Please submit the completed form with a readable signature and date via one of the following options: Fax: 1-888-548-0098 You can also mail the completed form to: Enrollment Department P.O. Box 151108 Tampa, FL 33684 Or you can contact Medicare at 1-800-Medicare (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should contact 1-877-486-2048. When should I fill out the disenrollment request form? You should fill out the form if you want to change to Original Medicare only and do not want Medicare prescription drug coverage. You shouldn’t fill out the form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan. You shouldn’t fill out the form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from Optimum HealthCare to Original Medicare. Until your disenrollment date, you must keep using Optimum HealthCare’s doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of Optimum HealthCare’s network. For more information, please view Your Rights and Responsibilities as a Member of our Plan. If you need any help, please call us at 1-866-245-5360. TTY users should call 711. From October 1 to March 31, we are open 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, 8 a.m. to 8 p.m. EST. Last updated 10/01/2021 Helpful Links CMS Model Electronic Complaint Form The Medicare Beneficiary Ombudsman Unable to view PDFs? Click here Benefits During Disasters and Catastrophic Events Click here for Multi-Language Interpreter Service Servicios de interpretación en varios idiomas (Multi-Language Insert) | (Inserción de varios idiomas) Section 1557 Notice of Non-Discrimination: English | Spanish Hours From October 1 to March 31, we are open 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, 8 a.m. to 8 p.m. EST. Telephone Toll Free 1-866-245-5360 TTY/TDD: 711 Mailing Address P.O. Box 151137 ATTN: Optimum Healthcare Tampa, FL 33684 Service Cities SERVING THE FOLLOWING AREAS IN FLORIDA: Brevard County Broward County Citrus County Charlotte County Collier County Hernando County Hillsborough County Indian River County Lake County Lee County Marion County Manatee County Martin County Orange County Osceola County Palm Beach County Pasco County Pinellas County Polk County Saint Lucie County Sarasota County Seminole County Sumter County Volusia County Website Disclaimer Optimum HealthCare, Inc. is an HMO with a Medicare contract and a contract with the state of Florida Medicaid program. Enrollment in Optimum HealthCare, Inc. depends on contract renewal. This Information is not a complete description of benefits. Call 1-866-245-5360 (TTY: 711) for more information. Medicare beneficiaries may also enroll in Optimum HealthCare through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system. Optimum Healthcare, Inc. has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Chronic Condition Special Needs Plan (C-SNP) through 2022 and a Dual Special Needs Plan (D-SNP) until 2024 based on a review Optimum Healthcare, Inc.’s Model of Care. Optimum HealthCare, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Optimum HealthCare, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Optimum HealthCare, Inc. konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-245-5360 (TTY: 711). Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-245-5360 (TTY: 711). These materials may be made available in alternate formats (e.g., large print, Braille) to individuals with disabilities, upon request. RETURN TO TOP Toll Free 1-866-245-5360 TTY/TDD: 711 OTC Home | About Us | Careers | Contact | Privacy Policy H5594_Website | © 2021 Optimum HealthCare Inc.