Patient Opt-Out / Revoke Opt-Out

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What would you like to do? : (*)	Elect to Opt Out Revoke Opt Out Must select an option to Opt Out or Revoke a previous Opt Out decision
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	The following patient information is required in order to ensure proper execution of this request.
First Name: (*)	Invalid Input
Last Name: (*)	Invalid Input
Address Line 1: (*)	Invalid Input
Address Line 2:	Invalid Input
City:	Invalid Input
State:	Invalid Input
Postal Code:	Invalid Input
Home Phone:	Invalid Input
E-Mail:	Invalid Input
Date of Birth (mm/dd/yyyy): (*)	Invalid Input

Nebraska Health Information Initiative