Health Care 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 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

Enter your 10 digit number. Please do not include spaces or dashes.

Aetna provider ID number (PIN)

Enter your PIN. ID number can be a maximum of 10 digits. 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 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.

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Contact information for contracting at new location in same state

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.

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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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

Contracting at new location in a new state

4.) Contracting at new location in a new state

Contact information for contracting at new location in same state

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

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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

Contracting at new location in a new state

4.) Contracting at new location in a new state

Contact information for contracting at new location in same state

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

News

JavaScript is required

You are now leaving the Aetna website

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