Remove Provider From Existing Group

Please ensure all information is accurate and complete. This form manages provider information for your group. Required fields are marked '*'

Group information

Enter the primary group details.

Group Name Required

Please enter a value.

Business Name Required

Please enter a value.

Group NPI Required

Requires 10 numerical characters.

Group TIN Required

Requires 9 numerical characters.

State Required

Primary Location

Provide details about your primary location.

Primary Location Name Required

Please enter a value.

Primary Address Required

Please enter a value.

Primary Phone Required

Invalid phone number.

Primary Fax Required

Invalid phone number.

Billing Location

Provide details about your billing location.

Billing Location Name Required

Please enter a value.

Billing Address Required

Please enter a value.

Billing Phone Required

Invalid phone number.

Billing Fax Required

Invalid phone number.

Remove Provider From My Group

Provide your provider details to be removed.

Provider First Name Required

Please enter a value.

Provider Last Name Required

Please enter a value.

Provider Specialty Required

Please enter a value.

Provider Individual NPI Required

Requires 10 numerical characters.

Effective Date of Addition Required

Must be a valid date. Format: MM/DD/YYYY

Manage locations

Remove locations from your existing group.

Location 1 Name Required

Please enter a value.

Location 1 Address Required

Please enter a value.

Location 1 Phone Required

Invalid phone number.

Location 1 Fax Required

Invalid phone number.

Location 2 Name Required

Location 2 Address Required

Location 2 Phone Required

Location 2 Fax Required

Location 3 Name Required

Location 3 Address Required

Location 3 Phone Required

Location 3 Fax Required

Location 4 Name Required

Location 4 Address Required

Location 4 Phone Required

Location 4 Fax Required

Location 5 Name Required

Location 5 Address Required

Location 5 Phone Required

Location 5 Fax Required

Location 6 Name Required

Location 6 Address Required

Location 6 Phone Required

Location 6 Fax Required

Location 7 Name Required

Location 7 Address Required

Location 7 Phone Required

Location 7 Fax Required

Location 8 Name Required

Location 8 Address Required

Location 8 Phone Required

Location 8 Fax Required

Completed by

Provide contact information for the person completing this request.

Completed By Name Required

Please enter a value.

Completed By Email Required

Please enter email value in format 'mymail@domain.com'.

Completed By Phone Number Required

Invalid phone number.

Phone Extension (optional) Required

Completed By Comments Required 0/100

Please enter a value.

If you need to remove more locations than permitted on this form, please complete another form for the remaining locations.