Disenrollment Chat Survey | Driscoll Health Plan

Our records show that you’re leaving Driscoll Health Plan. We’re sorry to see you go. Please complete our quick survey to let us know why you’re leaving and help us improve our services.

Name:(Required)

First Last

Birth date:(Required)

Mobile number:(Required)

Please let us know the reason you are leaving.(Required)

You may select more than one.

Moving out of the area

Doctor not in-network

Difficulty getting Value Added Services (ex. Gift cards, over-the-counter products, etc.)

Other health plan Value Added Services (ex. Extra benefits, gift cards, over-the-counter products, etc.)

Difficult getting authorizations/approvals

Combining family to one health plan

Please tell us the name and type of doctor:(Required)

Please tell us what kind of issues you had:(Required)

Please tell us what services you were interested in:(Required)

Please tell us what kind of services you had difficulty with:(Required)

Did you file an appeal after being denied?(Required)

Yes

Please provide any details you would like to share:

Reason for Leaving Driscoll Plan