Versant Health Provider Termination Form

Provider Termination Form

This form will only apply to the location and/or practitioner(s) provided.
The Participating Provider Agreement may be terminated upon ninety (90) or sixty (60) days depending on contract prior, written notice. Providers shall continue to provide Covered Services to a Member who is receiving Covered Services on the effective termination date of this Agreement for a minimum transitional period of sixty (60) days from the date the Member is notified of the termination or pending termination, or until the Covered Services being rendered to the Member are completed.
Request termination from the following network(s)*

Davis VisionSuperior VisionBoth Davis Vision and Superior Vision
Request termination for the following

OfficePractitioner
Does this practice currently have the Exclusive Frame Collection?*

YesNo
Office ID*
Enter office ID of where the collection is currently being housed.
If you answered yes above, a request for your return materials for shipping the frame collection back to us will be sent around 3 weeks prior to the term date. Please confirm the address you would like your return materials sent to. The box that will be sent will be flat with the return label inside, when you pop it open, it will have exactly 222 slots one for each frame. We do not need the tower returned, you can throw it out or recycle as you see fit.*
Enter address to send return material and shipping label.
Date of Request*

MonthDayYear
Date
Requestor's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Effective Date of Termination*

MonthDayYear
Select a future date. The Participating Provider Agreement may be terminated upon ninety (90) days or sixty (60) days depending on contract prior, written notice.
Needing to terminate multiple offices at once? If yes, a Provider Termination Form per office location will be required*

YesNo
Office Information
Office ID*
Office Name*
Address 1*
City*
State
State*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code*
Zip Code Tax ID*

ZipTax ID Number
Tax ID*
Needing to terminate multiple Practitioners at once? If yes, select the + button below and add each additional Practitioner.*

YesNo
Practitioner Name*

First NameLast Name
Practitioner NPI*
Additional Practitioner(s)*
Reason for Termination
Please indicate all termination reasons*

Closed PracticeDoctor RetiredDoctor DeceasedDoctor Left the Office/GroupSold PracticeCombined PracticesReimbursement RatesLab QualityLab Turnaround TimeDissatisfied with CommunicationScaling back/Ending Managed Care participationOther
Sold or Combined the Practice, please identify the associated Practice
Practice Name blanks*. Davis Vision and/or Superior Vision Office Numberblank*.
Lab Quality:*

EssilorNewtown Square
Lab Turnaround Time:*

EssilorNewtown Square
Dissatisfied with Communication:*

Call CenterNetwork ServiceOther
Please follow the link to complete a Provider Change Form.
Versant Health Provider Change Form
Sell of Practice/Ownership Change requires a W-9 and Bill of Sale.
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Authorized Signer Name*

First NameLast Name
This form will only apply to the location and/or practitioner(s) provided.
To request a termination for another location and/or practitioner, please complete another Provider Termination Form after this submission.
Should be Empty:

Provider Termination Form

Office Information

Reason for Termination