Practice Location Termination Notification

Practice Location Termination Notification - Practice Health
Term Effective Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Practice Name
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tax ID
Group NPI
List of Provider(s)
If PCPS: Patients to be Assigned to?
Reason for Terming
Manager Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By providing this notification, the provider and practice understand that the provider listed above will be terminated from Rose Medical Group dba Practice Health membership; this includes termination from participation in all payor contracts and group purchasing agreements held by Practice Health on or after the termination date noted above.

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

Practice Location Termination Notification - Practice Health