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How to terminate your participation with Aetna®

Provider termination request form

If you or a provider in your group are joining or leaving the group, relocating, retiring or if a provider is deceased, we’re here to help. Simply use this form to terminate from the current contracted location.


Need to terminate a full contract? Please don’t use this form. Instead, you can follow the termination notification provisions (labeled as TERM) in your contract. 

The information you give us is also used to update our provider tools.


All fields marked with an asterisk (*) are required.


1. Requester information (at provider’s office)

e.g., office manager
Formatted as

2. Terminating provider information


A 9-digit number is required. Do not include spaces or dashes, e.g., 123456789.
Enter your 10-digit National Provider Identifier number. Do not include spaces or dashes, e.g., 1234567890.
Enter your PIN, which can be a maximum of 10 digits. Do not include spaces or dashes, e.g., 1234567890.

3. Termination details

Terminate from:
Enter date as mm/dd/yyyy. Note: If a provider is relocating to another state or leaving a group practice, they will be considered nonparticipating as of the termination effective date entered.
This form should only be used for the reasons noted. This form should not be used to terminate a provider agreement/contract. For these requests, please contact your local network representative.

4. Contracting at a new location in a new state

Relocating to a new state? After completing this termination request, you can fill out a Request for Participation to start the contracting and credentialing process. 


5. Contracting at a new location in the same state

Leaving a group and starting another practice, or joining a new practice or group? If you enter some details below, we’ll get in touch with you to discuss contracting at your new location. Note: Until you sign a new agreement, the new tax ID number and location are considered out of network.

Enter a 9-digit number. Do not include spaces or dashes, e.g., 123456789.
Formatted as
Formatted as
Enter a 10-digit number, e.g., ###-###-####

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

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