Terminate/Close a Practice

"*" indicates required fields

Please complete the following information to close a practice/group.

Effective Date*

Group/Entity NPI*

Group/Entity Name*

Group/Entity TIN*

Practice Name*

Practice NPI (if applicable)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone*

Practice Fax*

Provider(s) Impacted by Update

Provider's Full Name*

Provider NPI*

Provider Specialty at this location*

Provider Specialty at this location *

Name of provider assuming panel*

Provider NPI*

Specialty (Must match the Provider's PCP role)*

Provider's Full Name

Provider NPI

Provider Specialty at this location

Provider Specialty at this location

Name of provider assuming panel

Provider NPI

Specialty (Must match the Provider's PCP role)

Provider's Full Name

Provider NPI

Provider Specialty at this location

Provider Specialty at this location

Name of provider assuming panel

Provider NPI

Specialty (Must match the Provider's PCP role)

If additional providers are impacted, please attach a list (Excel or Word) that includes the provider's full name and NPI

Max. file size: 200 MB.

Details for the person submitting the form

Name*

Title*

Phone Number*

Email*

Date

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