Specialist Term

Specialist NPI # *

Specialist Name

First Name *

Last Name *

Tax ID # * Practitioner will be termed from all locations associated with this TIN

Group Name *

Group NPI # *

Provider One ID (Please write Ambetter Only in this box if not enrolled with IHCP)

Service Location Address

Street Address *

Address Line 2

City *

ZIP / Postal Code *

State *

Date Term Effective *

Other (Reasons)

Programs to Term (choose all that apply) * Apple Health Medicaid (AHMC) Apple Health Core Connections Ambetter from Coordinated Care

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

Additional Attachments