Physician Termination of Participation Form

HEALTHLINK | PHYSICIAN TERMINATION FORM

Please note: The use of this form is for termination of participation with HealthLink

Requestor Information

* Name

* Phone

* Email

Provider Information

* Provider Name

Provider HealthLink Number

* Provider TIN

Provider NPI

Provider Email Address (if different from the requestor's)

Reason for Terming

Check on the type of changes(s) you are making:

Moving Out of Service Area

Retirement

Leaving Group Contract

Dissatisfied

Other

Please have a Network Contractor contact me

Effective Date of Termination

Please refer to Notification of Termination provisions in your contract.

* Effective Date of Termination (mm/dd/yyyy)