PCP Term

Primary Care Provider (PCP) NPI # *

Primary Care Provider (PCP) Name

First Name *

Last Name *

Degree *

Tax ID # * Practitioner will be termed from all locations associated with this TIN

Group Name *

Group NPI # *

Group Medicaid Number *

If the provider is still working for your Group, and only needs to remove a physical location tied to your Group NPI, please refer to the Demographic Update Tool section: Make and Address Change and Choose “Remove a Location".

Date Term Effective *

Other (Reason)

Programs to Term (choose all that apply) * Ambetter from Magnolia Health Magnolia Health Behavioral Health

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

Move Members To (choose one): * Auto-Assignment Provider

If there is a specific provider you would like this PCP's member (s) reassigned to, please complete the following otherwise they will be auto assigned.

Provider #1 NPI *

Provider #1 TIN *

Provider #1 First Name *

Provider #1 Last Name *

Provider #2 NPI

Provider #2 TIN

Provider #2 First Name

Provider #2 Last Name

Provider #3 NPI

Provider #3 TIN

Provider #3 First Name

Provider #3 Last Name

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Last Updated: 01/29/2025