Membership Cancellation Notice
Provide your details and cancellation reason to start the 90-day notice process.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
*
example@example.com
Reason for cancellation
*
Cost or financial reasons
Moving to another provider
No longer need the service
Health needs have changed
Not seeing the results I hoped for
Time commitment
Other
*
I understand that Aurelia Health requires 90 days' notice to cancel my membership and any membership in billing will continue through the 90-day notice period. I also understand that my care remains active until my confirmed final in date.
*
I understand that I will be provided with a 90 day supply of medications and that the Aurelia support team will ensure I have an off boarding call scheduled with my clinical team.
Is there anything you would like us to know?
What happens next
Your membership and care stay active for the full 90-day notice period.
Billing continues on your normal schedule through the notice period.
Our team will email you to confirm your final payment date.
Your clinical team will schedule an offboarding call with you before your final date to ensure you have an Rx plan in place.
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