Health 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)

* First name

* Last name

* Requester title

* Requester email address (formatted as sample@example.com)

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Terminating provider information

2.) Terminating provider information

* Provider first name

* Provider last name

Provider middle initial

* Address

* City

*State

*5 digit ZIP code

* Tax identification number (Tax ID)

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

NPI number

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

* Aetna provider ID number (PIN)

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:

Aetna

Coventry

Both under the tax ID number noted above

* Termination effective date (entered as mm/dd/yyyy)

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.

* The reason for individual provider termination is:

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.

New tax identification number (Tax ID)

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

Contact first name

Contact last name

Contact email address (formatted as sample@example.com)

Verify contact email address (formatted as example@sample.com)

Contact phone number (10 digits)

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Medical Professionals

Dental Professionals

Provider Termination Request Form

Requester information (at provider’s office)

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

Terminating provider information

2.) Terminating provider information

Termination details

3.) Termination details

Contact information for contracting at new location

4.) Contact information for contracting at new location

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Provider Termination Request Form

Requester information (at provider’s office)

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

Terminating provider information

2.) Terminating provider information

Termination details

3.) Termination details

Contact information for contracting at new location

4.) Contact information for contracting at new location

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