Information Changes Regarding Your Participation

The purpose of this form is to allow you to elect whether to participate in PPO dental products through DHA's upcoming arrangement with Metlife. If you have questions or comments about this form, please call 800-434-2638.

You previously received notice of this arrangement. For additional information please visit www.dha.com/announcement.html.

Please complete the entire form and then click Done. You will not be able to save a partially completed form.

*NOTE: You must answer all questions in order to submit this form.

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* 1. By completing this form, I acknowledge that the election below will be applied to the provider NPI and location ID number supplied below.

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* 2. Please type in the provider NPI number. (This number is ten digits)

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* 3. Please enter your state abbreviation. (Example: WI)

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* 4. Please type in the location ID number. This is a 3-8 digit number printed above your address on the envelope. See example.

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Here is an example of the location ID on your envelope.

Here is an example of the location ID on your envelope.

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* 5. Do you wish to opt out of Metlife dental plans through your participation with DHA?

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* 6. By submitting this form, I hereby attest that: (1) the foregoing response is correct and, (2) I am authorized to make this election on behalf of the provider at the referenced location.
This will also serve as your signature authorizing us to implement this election.

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* 7. Please provide an email address for who we should contact if we have any questions.

*The DHA Dentist Guide contains additional information about conducting business electronically with us.

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