Zelis Opt-out Letter - Florida

Florida Opt-out Letter
Re: Request to Opt-Out Participation with DHA (SunLife), Decare/Wellpoint, & United Healthcare through Zelis

Dear Zelis Provider Services Representative:

Please be advised that the doctor and practice above would like to opt-out his/her DHA (SunLife), Humana, & United Healthcare through Zelis.

We thank you in advance for your attention in this matter. Please confirm receipt of this notice.
Date*

MonthDayYear
Date
Practice Name:
Practice FEIN:
Provider Name:
Provider NPI:
Address:
Signature:

Clear
Name and Title:
Should be Empty: