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Provider termination request form

Do not complete this form if you want to terminate a full contract. To terminate a contract, please follow the termination notification provisions (labeled as TERM) in your contract.

 

Use this form if you or a provider in your group need to terminate 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

 

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 example@sample.com
 

2.) Terminating provider information

*Address

A 9 digit number is required. Do not include spaces or dashes.
Enter your 10 digit number. Do not include spaces or dashes.
Enter your PIN. ID number can be a maximum of 10 digits. Please do not include spaces or dashes.
 

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.
This form is to be used for the following reasons only.  It is not intended to be used for termination of a provider agreement/contract, and you will need to contact your local network representative directly for these requests.
 

4.) Contracting at new location in a new state

 

If you are relocating to a new state, after completing this Termination request, then complete a Request for Participation to initiate the contracting and credentialing processes.

 

5.) Contact information for contracting at new location in same state

 

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.
Formatted as example@sample.com
Formatted as example@sample.com