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Contact us Tel: 0860 103 933, PO Box 652509, Kenmore 2010, www.lahealth.co.za Membership/dependent withdrawal form Employer HR Date Stamp How to complete this application form 1. 2. 3. 4. To be completed

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What is la health withdrawal form?

The LA health withdrawal form is a document used to formally notify the relevant authorities in Louisiana about the withdrawal of an individual's or entity's participation in a health program or insurance plan.

Who is required to file la health withdrawal form?

Individuals or entities participating in Louisiana health programs or insurance plans who wish to terminate their involvement are required to file the LA health withdrawal form.

How to fill out la health withdrawal form?

To fill out the LA health withdrawal form, individuals must provide their personal information, details of the health program or insurance plan they are withdrawing from, and any required signatures as specified in the form's instructions.

What is the purpose of la health withdrawal form?

The purpose of the LA health withdrawal form is to officially document and process the withdrawal of an individual or entity from a health program or insurance plan, ensuring that records are updated accordingly.

What information must be reported on la health withdrawal form?

The information that must be reported on the LA health withdrawal form includes the participant's identification details, reasons for withdrawal, the specific program or plan being exited, and any applicable date of withdrawal.

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