Skip to main content
CONTACT US
Search form
Search
Main Menu
About Us
Partners & Affiliates
Members
Providers
Provider Login
Care Management
Claims
Credentialing
Forms
Provider Relations
Plans and Resources
CareSource Marketplace
Managed Health Services
School City of Mishawaka
St. Joseph County Government
Choosing Wisely - Education Tools
Provider Connection Newsletters
Quality Measures and Utilization Management Guidelines
Care Management
Find A Provider
Provider Termination
Effective Date of Termination
*
Date
*
Provider Information
Practitioner Name
*
Address
Country
- None -
United States
Address 1
*
Address 2
City
*
State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
--
Armed Forces (Americas)
Armed Forces (Europe, Canada, Middle East, Africa)
Armed Forces (Pacific)
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
ZIP code
*
Phone Number
*
Fax Number
*
Practice Manager
Practice Manager e-mail address
Termination Detail
Moved out of area
*
Yes
No
Moving Location
Provider Retired
N/A
NO
YES
Provider Death
N/A
NO
YES
Other Reason
N/A
NO
YES
Reason Detail
Please attach a termination letter with your submission.
*
Upload
More information
Files must be less than
10 MB
.
Allowed file types:
pdf doc docx tiff
.
Submit
Back to top
