Contracted Practitioner Term
Requestor Name
*
Requestor Email
*
PRACTITIONER INFO
Practitioner First Name
*
Practitioner Middle Name
Practitioner Last Name
*
Practitioner Credentials
*
Individual NPI #
*
Specialty
*
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Term Reason
*
Closing Practice
Deceased
Hospitalist
Inactivated Credentialing
Leaving Area
Left Practice
License Expired
Provider Initiated
Retired
Term Instructions
Term Practitioner from Care Site Only
Term Practitioner from Tax ID
Main Care Site Name
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Main Care Site Street Address
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Effective Date
*
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Calendar
Tax ID or Provider #
*
Forwarding Address for Termination Letter
Is this the last practitioner at this care site?
*
Yes
No
Do you anticipate hiring another practitioner for this care site?
*
Yes
No
Location provider moved to, if known?
PCP?
*
Yes
No
Practitioner(s) absorbing Primary Care Panel
Solo Practitioner?
*
Yes
No
Requestor Comments
Source
Lexis Nexis report
Stoplight report
Email
TRM Report
Appt. Access
Attestation report
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