Provider Termination You must have JavaScript enabled to use this form. Effective Date of Termination Date Provider Information Practitioner Name Practice Name Practice Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Fax Practice Manager Practice Manager e-mail address Termination Detail Moved out of area Yes No Moving Location Provider Retired N/A No Yes Provider Death N/A No Yes Other Reason N/A No Yes Reason Detail Enter other… Please attach a termination letter with your submission. Upload One file only.16 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml. Submit
