Opt out Form

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Opt Out

Would you like to opt out of the health plan ?(Required)

Yes, I would like to opt out

I have a question about the health plan before I decide

Email(Required)

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Contact ID

DOB(Required)

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ID

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Date

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Compare Opt Out Date

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Opt Out Status

It seems that we couldn’t validate your information in our system. Please enter your information below and a Account Manager will get back with you.

It looks like you are outside of your opt-out period. For assistance, please call 866-826-2934 or enter your information below and a Account Manager will be in touch to discuss your options

You have already Opted Out, if you have additional questions, please fill out the below inquiry form

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Verify count

Name(Required)

First Last

Company Name(Required)

Phone(Required)

How would you like to be contacted?(Required)

Phone

Email

No preference

Question(Required)

Confirmation(Required)

After reviewing the plan details, I confirm by submitting this request, that I am opting out of both the benefits and the slightly bigger paycheck.

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Patient Name

First Last

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App Profile ID

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Company Name

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Employee ID

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