FCS Disenrollment Form

Complete this form if you want to disenroll an enrollee from the Foundational Community Supports (FCS) program.


FCS providers who wish to disenroll an inactive enrollee must conduct due diligence. This involves reaching out to the FCS enrollee at least four times over a period of six weeks or longer and using a minimum of two different communication methods.


For questions, please call FCS at 844-451-2828 (TTY 711) Monday through Friday from 8 a.m. to 5 p.m. Pacific Time or email at

FCSTPA@wellpoint.com.