[firstName] [middleName] [lastName]
[patientAddress]


Dear Veteran,

This letter is to inform you that your eHealth Exchange authorization has been revoked for the following reason(s):

[optoutReason]

Sincerely,
[signature]

*To learn more about Premium eBenefits accounts, go to:
https://ebenefits.custhelp.com/app/answers/detail/a_id/1669/~/
what-are-the-requirements-for-getting-a-premium-ebenefits-account%3F.