Prescriber Tool APM Contact Update and Opt-Out Form

Prescriber Tool APM Contact Update and Opt-Out Form

Name of Submitter*

First and last name

Title of Submitter*

Submitter Email*

I would like to:*

Check all that apply.

Select practice NPI(s) to Opt Out

Select practice NPI(s) to update contacts

Practice NPI(s) to opt-out of the program*

You can type in the NPI as you are selecting and you can select multiple NPIs.

If one or more of your practice NPIs do not show in the dropdown list, please select "OTHER" and add missing NPIs on the next question.

Select

Missing practice NPI(s) to opt out.

Please separate multiple NPIs by a comma.

Waiver*

I understand that by choosing to opt-out, the practices selected will be ineligible for shared savings payments for program year 2 (if the Department does not receive a completed feedback survey by the closing of the activity window.)

Practice NPI(s) to update contact*

You can select multiple NPIs if the contact update is the same for all selected.

If one or more of your practice NPIs do not show in the dropdown list, please select "OTHER" and add missing NPIs on the next question.

Select

Missing practice NPI(s) to update contact information

Please separate multiple NPIs by a comma.

Primary Practice Contact Name*

First and last name

Primary Practice Contact Email*

Secondary Practice Contact Name

(Optional) First and last name

Secondary Practice Contact Email

(Optional)

Send me a copy of my responses

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