Contracted PHO / IPA Name

Opt-In/Opt-Out Letter

Multi –TIN Agreement

Tax Identification Number (TIN) Name:

TIN:

TIN NPI Number:

Please indicate your response in one of the boxes below:

Opt-In (ADD):

□ As signature authority for the TIN listed above, I have reviewed the TRICARE Contract, Fee Schedule, Provider Manuals and TRICARE requirements and have decided to “ACCEPT” the ____TIOPA____ contracted rates and be bound to the terms of

(Entity Name here)

said agreement. My signature below represents my “ACCEPTANCE” and willingness to participate. I acknowledge all physicians under the above Tax Identification Number are included and will be notified of their effective date.

Owner of Tax Identification Number (TIN):

______

Signature Date

______

Printed Name Title

______

Printed Phone

Submit W-9

Opt-Out (TERMINATION):

□ As signature authority for the TIN listed above, the TIN will no longer be participating under the Multi-TIN agreement known as ______.

(Entity Name here)

HMHS Opt In / Opt Out Letter

10/15/2010 - Final