Practitioner Last Name: The last name of the individual practitioner as listed on the state license where care is being rendered

Practitioner First Name: The first name of the individual practitioner as listed on the state license where care is being rendered

Practitioner Middle Initial: The middle initial of the individual practitioner as listed on the state license where care is being rendered

Practitioner NPI: The unique 10-digit identification number assigned to the health care practitioner being terminated

Credential / Degree: Credential(s) or degree(s), representing education and ability to provide care, awarded to the  healthcare practitioner being terminated

Termination Date: The last date the terminating practitioner is eligible to see patients or employed by organization

What location(s) is practitioner terminating from? The name of the facility or facilities from which the practitioner is terminating

Practicing Site Name / City: Name and address of location(s) practitioner will continue to practice, if applicable

Billing NPI: The unique 10-digit identification number for covered health care providers

Tax ID: The nine-digit identification number used by the Internal Revenue Service in the administration of tax laws for this practitioner

If practitioner is a Primary Care Physician, who will be taking members currently assigned to practitioner? The first and last name of the primary care physician(s) who will continue care for impacted members

If practitioner is a Specialist, who will be taking referrals that were assigned to practitioner? The first and last name of the specialist provider(s) who will continue care for impacted members

How will members be notified of this change? List all communication methods utilized to notify members of terminating practitioner

If this was the only practitioner at the site, will the practitioner be replaced? Select Yes or No

If so, when? Enter the effective date for the replacement practitioner

Where will the terminating practitioner be going (required by Wis. Law)? If known, provide the organization or facility name to which the terminating practitioner is relocating. If unknown, state “unknown”

Practice Site Name / City: If known, provide the city and state to which the terminating practitioner is relocating

Phone: If known, provide the telephone number for the location to which the terminating practitioner is relocating

Why is practitioner leaving? Select of the choice that best describes the reason the practitioner is leaving from the drop down list

Completed by: Name of the individual completing this form. Individual must be authorized to represent the provider office for enrollment with health insurance payers

Email Address: Email address of the individual completing the form

Phone: Telephone number for the individual completing the form