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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Please list the providers that are no longer active at your practice and the date of inactivity.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
1.  ***

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

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