Practitioner Voluntary Termination Form

To provide Meridian Notice of Voluntary Termination of a practitioner, please download and fill the Termination Form Template below, and upload to the form.

Termination Form Template (Excel | .xlsx)

Voluntary Termination Form Upload *

Providers must give Meridian Health Plan notice of voluntary termination following the terms of their participation agreement. Meridian Health Plan must notify affected enrollees covered under the terminating agreement at least 30 calendars days prior to the effective date for any termination. For more information, please review our provider manual.

Please attest to the following:

I understand that in order to provide 30-day prior notice to affected members my effective date of voluntary termination must be at least 30 calendar days from notification.

Termination requested by:

First Name: *

Last Name: *

Contact Email: *

Contact Phone Number *

Last Updated: 11/01/2024