Opt-Out of Manifest MedEx

En Español

Participation in Manifest MedEx is completely free and voluntary. To opt out of Manifest Medex, complete and submit the information below, or call (800) 490-7617.

By opting out of Manifest MedEx, you are choosing not to have your personal health information accessible by your healthcare team and your health plan through the Manifest MedEx system.

You will receive an email confirmation that your opt-out request has been processed. If the information you provide when opting out changes before you receive confirmation, please resubmit your request.

You can make a request to rescind opt-out by clicking here.

I am submitting this form for myselfI am submitting this form for someone else

Your name *

Gender *

Date Of Birth *

Previous First Name

Previous Last Name (Maiden, Other)

Your Address *

Your Email Address *

Your Phone Number *