Terminated Provider Form

Name of Person Submitting Form*

First

Last

Email Address of Person Submitting Form*

Enter Email

Confirm Email

Health Center / Client Name*

I am an existing Shareholder*

Yes
No

Termination Date:*

MM

DD

YYYY

Date the provider will no longer be contracted with the organization

Provider Name*

First

Last

Degree*

Specialty*

Corporation Name*

Practice Location Name*

Practice Location Address*

Street Address

Address Line 2

City

State

ZIP Code

Practice Phone Number

Practice Fax Number

Tax Identification Number*

Practice Site NPI Number*

Does this provider have patient panels assigned to him/her? ***The answer is YES for PCP providers only (i.e., MD, DO). Please list the name of the provider who will assume the terminating provider’s patients.*

• Provider Assuming Patient Panels ***Please be sure that the assuming provider listed is available at the terminating provider’s primary practice and is either an MD or DO practicing in the fields of Family Medicine, Pediatrics, or Internal Medicine.

First

Last

Are billing services provided to this client by the Cenevia Central Billing Office?*

Has a mapping form been completed by the client and submitted to the Central Billing Office?*

The above named primary provider has agreed to map the following provider in order to bill for services rendered:

First

Last

Mapped Provider Specialty