Primary Care Provider (PCP) Term

Primary Care Provider (PCP) NPI # *

Primary Care Provider (PCP) 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 (Reason)

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

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

Move Members To (choose one): * Auto-Assignment Provider

Provider #1 NPI *

Provider #1 First Name *

Provider #1 Last Name *

Provider #2 NPI

Provider #2 First Name

Provider #2 Last Name

Provider #3 NPI

Provider #3 First Name

Provider #3 Last Name

Additional Attachments