Terminate a Provider From a Currently Active Location/Practice or Network Participation

Please complete the following information to terminate a provider from a contracted group/entity, location, or network participation with Neighborhood Health Plan of Rhode Island.
Effective Date*
MM slash DD slash YYYY
Termination Request Type (select all that apply)*
- Term from Group/Entity
- Term from location
- Term from network
Group/Entity NPI*
Group/Entity Name*
Group/Entity TIN*
Provider Name*
Provider NPI*
Primary Specialty*
Practice Name*
Practice NPI (if applicable)
Practice Address*
Street Address Address Line 2 City State ZIP Code
Practice Phone*
Provider Specialty at this location*
Provider Specialty at this location *
- PCP
- Specialist
Name of provider assuming panel*
Provider NPI*
Specialty (Must match the Provider's PCP role)*
Reason for Termination*
Reason for Termination *
- Retirement
- Moved out of state
- Left Practice
- Other
Other
Additional Information Required to Process PCP Termination Request
Details for the person submitting the form
Name*
Title*
Phone Number*
Email*
Date
MM slash DD slash YYYY
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