Opt-out Letter - Texas

Texas Opt-out Letter
Re: Request to Opt-Out of Participation with DHA & United Healthcare through Zelis

Dear Zelis Provider Services Representative:

Please be advised that the doctor and practice above would like to opt-out their DHA & United Healthcare 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:*

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Name and Title:*
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