Zelis Opt-out Letter - Oklahoma

Oklahoma 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 participation through, Zelis.

We thank you in advance for your attention in this matter.
Date*

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

Clear
Name and Title:*
Should be Empty: