Opt Opt-Out Referral Form by wuyunqing

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									2308 Killearn Center Blvd. Bldg A1
Tallahassee, FL 32309

                  Opt-Out Referral Form
                                     (Please Print)


Medicaid ID#:

Recipient Name:

Recipient Address:



Recipient Phone #:

Employer Name:

Employer Address:



Employer Contact Person:

Employer Contact Phone #:

Medicaid Reform Plan Name:

Desired Health Plan Name:

Reason for Opting Out:



       Complete this section if currently enrolled in a workplace health plan
Insurance Company Name:

Insurance Company Address:



Policy Holder:

Policy Number:

  Please return Referral Form in the enclosed envelope. You can also fax form to (866)
   443-5559. If you have any questions regarding the completion of this form, please
       contact the Medicaid Opt-Out Department at (877) 357-3268 or email us at
                              floridaoptout@acs-inc.com.

								
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