If you have submitted an opt-out request already, but want to cancel/withdraw that request, complete the rescind form below.

To cancel your opt-out decision and enroll into the NYC Medicare Advantage Plus Plan, please complete the form below. You can submit this form online, which is preferred. Or you can call 1-833-325-1190. If you do not prefer to use the online or call in options, you can mail a written request to: NYC Medicare Advantage Plus Plan, PO Box 1620, New York, NY 10008-1620. The written request must include your name, address, date of birth, Medicare Beneficiary Identification number (from your Medicare Card), full Social Security Number and signature. Each Medicare-eligible participant (i.e., retiree, spouse, or dependent) must complete a separate rescind form.

If you have not opted out of the NYC Medicare Advantage Plus Plan, you do not need to complete this form.

If you want to stop your City of New York retiree health coverage altogether, complete the NYC Health Benefits Application/Change Form. This form is available on the Health Benefits Program website at: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-forms-and-downloads.page . Please understand you will NOT be eligible for reimbursement by the City of New York for your Medicare Part B premium if you stop your City of New York retiree health coverage. You may, however, re-enroll in City retiree health benefits during the next Transfer Period.

NYC Medicare Advantage Plus Plan Rescind Form

Complete this form if you wish to cancel your previous opt-out request.

This section should be completed by the person canceling their opt-out request:

Complete this section with the City Retiree's information:

By providing my name below as an electronic signature, I elect to rescind (cancel/withdraw) my previously submitted opt-out request and enroll into the NYC Medicare Advantage Plus Plan.

Electronic Signature of participant cancelling their opt-out request

Date: 07/05/2022

Please re-type your name in the spaces below to confirm your electronic signature.

Date: 07/05/2022