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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
The information you give us is also used to update our provider tools.
All fields marked with an asterisk (*) are required.