Payer Termination Notification

Payer Termination Notification - Practice Health
Term Effective Date:*

MonthDayYear
Date
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tax ID*
Group NPI*
List of Provider(s)*
Which Payer(s)*
Reason for Terming*
Manager Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
By providing this notification, the provider and practice understand that the provider(s) listed above will be terminated from Rose Medical Group dba Practice Health membership for the payer(s) indicated.

If you have any questions, please reach out to Practice Health at (303)320‐2073. Once completed, please email to info@practice-health.com.
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Payer Termination Notification - Practice Health