Physician Option to Decline Future Notices
Please complete and submit this form to decline receipt of future notices from WHA Information Center about publicly available records that may contain your medical license number. Fields marked by an asterisk (*) are required.
First Name:
*
Middle Initial:
Last Name:
*
License #
*
Email:
Credential:
*
-- Select Credential --
MD
DO
Telephone Number:
*
(xxx-xxx-xxxx)
I elect to decline future notices:
*
Problems or questions: Please contact Ashley Austin at aaustin@wha.org, 608-274-1820 or 800-231-8340.