Term an Existing Provider

What do you want to do? *

Primary Care Provider (PCP) Name

Practitioner will be termed from all locations associated with this TIN.
Programs to Term (choose all that apply) required *
Move Members To: *

Update Requested By

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.

Specialist Name

Practitioner will be termed from all locations associated with this TIN.
Programs to Term (choose all that apply) required *

Update Requested By

This form will send your message to Ambetter from MHS as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter from MHS through email, you accept associated risks. Ambetter from MHS does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your PHI, please send us a message through the Secure Member or Provider portal.