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Notice of Inactive Providers

Please list the providers that are no longer active at your practice and the date of inactivity. For changes to Tax Id#, address or ownership, a new contract must be submitted.
*Required Field


Requested By* 

 
Business Name* 

 
Office Address* 

A separate form is required for different locations.
 
Business Tax ID* 

Numbers only
 
Business Email* 

 
Confirm Email* 

 
Inactive Provider Full NameLicense ID
Numbers only
Inactive Date
mm/dd/yyyy
1.  ***
2.        
3.        
4.        
5.        
6.        
7.        
8.        


Please enter the form authorization code in the text box below.

 
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