Location Termination Form

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

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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.
Contact Phone is Required.

*Indicates a required field