Location Termination Form

This form should be used when a clinic is closing or relocating. If relocating, also complete the New Location Form.

Need Help Filling out this form?

Termination Date is Required.
Terminating Location is Required.
Physical Address is Required.
City is Required.
State is Required.
Zip Code is Required.
Format: XXX-XXX-XXXX
Phone Number is Required.
Billing NPI is Required.
Tax ID is Required.
Termination Reason is Required.

Where are practitioners relocating?*

Practitioner Name New Site Practitioner NPI#
List site in Wisconsin, or list state if relocating (required by Wisconsin law.)

Contact Name is Required.
Contact Email is Required.
Format: XXX-XXX-XXXX
Contact Phone is Required.

*Indicates a required field