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Opting out of the Delta Dental Medicare Advantage Network is a two-step process:
Enter the information requested in the form below and click the "Submit Form" button at the bottom of the form.
Once the form is submitted, a document will be generated for you to sign digitally. The document will be emailed to the address submitted in this form.
To sign the document digitally, open the email and click the button labeled 'Review and Sign' and follow the instructions to sign and submit the document.
Contact Lori Langdeaux, Government Programs Policy Analyst, at email@example.com or 877-841-1478 if you have any questions about completing the form or the opt-out process.