Medicare Advantage network opt out

Provider information

Dentist name*

First Name

Last Name

SD license number*

Email*

Confirm Email *

The final opt-out form will be emailed to this address for electronic signature

Phone*

Practice opt-out

Practice name*

As recorded with the IRS

Tax ID number*

Confirmation of practice opt-out

I understand the opportunity to participate in Delta Dental of South Dakota’s Medicare Advantage provider network and hereby decline to participate in the network at the practice submitted in this form.*

I agree

I understand that if this is a group practice, my request to opt-out of the Medicare Advantage network will be processed only when every participating dentist associated with the practice has submitted an opt-out notification form.*

I agree

I understand this opt-out notification form is only applicable to the practice listed above. If I want to opt-out at another practice, I will need to submit a separate opt-out notification form for that practice.*

I agree

I understand I can opt back into the Medicare Advantage network at any time by contacting Delta Dental of South Dakota.*

I agree

Note:

When this 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. Please allow several minutes for the email to be delivered. If it doesn't show up in your inbox, check other folders (junk, promotions, update, etc., depending on your email client).
The email sender will appear as 'Professional Relations' at Delta Dental of South Dakota from the address 'InsureSign@send.insuresign.com'. The subject line will be 'Please review and sign: DDSD Medicare Advantage network opt-out'.
To sign the document to complete opt-out from the Medicare Advantage network, open the email and click the button labeled 'Review and Sign' and follow the instructions to sign and submit the document. You will then receive another similar email with a copy of the final signed document.