Zelis Opt-out Letter - Florida

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

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

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Practice Name:
Practice FEIN:
Provider Name:
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Signature:

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Name and Title:
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