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Provider Termination Request Form

This form is intended to communicate individual provider terminations (medical, behavioral health, dental, mid-level practitioner) from a currently contracted location for the following reasons:

  • leaving current group and starting/joining a new practice/group
  • no longer employed by the practice or group
  • relocating to another state
  • retired
  • deceased

This form is not to be used for termination of a provider agreement/contract.

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

All fields marked with a RED asterisk (*) are required.

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Requester information (at provider’s office)

1.) Requester information (at provider’s office)

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Terminating provider information

2.) Terminating provider information

A 9 digit number is required. Please do not include spaces or dashes.

A 10 digit number is required. Please do not include spaces or dashes.

A maximum of 10 digits is required. Please do not include spaces or dashes.

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Termination details

3.) Termination details

*Terminate from:

Please note: if provider is relocating to another state or leaving a group practice, they will be considered non par as of the termination effective date entered below.

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This form is not to be used for termination of a provider agreement/contract, and you will need to contact your local network representative directly.

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Contact information for contracting at new location

4.) Contact information for contracting at new location

If you are leaving a group and starting another practice or joining a new practice/group and want to be contacted to discuss contracting at your new location, please provide the information below. Until you sign a new agreement, the new tax ID number and location are considered out of network.

A 9 digit number should be entered. Please do not include spaces or dashes.

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