Opt-Out Form — BIG SKY CARE CONNECT

Opt-Out

You may choose to opt-out of participation in the BSCC or change a prior election by completing and signing this form. Click the button below to complete the form online.

Opt-Out Form

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Last 4 of SSN

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Requesting Individual

Please choose one of the following options that best fits your situation.

Consent Decision

Please choose one of the following options:

I request to opt-out of participating in BSCC.

I want to revoke my prior opt-out choice and fully participate in BSCC.

Electronic Signature

First Name

Last Name

Date Signed

MM

DD

YYYY

Name of Legal Representative (If applicable):

First Name

Last Name

You can also fill out this form and mail it to:

BSCC Opt-Out Team
2021 11th Avenue, Suite 11
Helena, MT 59601