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 firstname.lastname@example.org.
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