Termination Form for Clinic/Group Billing

Please complete this form to notify Arkansas Blue Cross and Blue Shield, Health Advantage, BlueAdvantage Administrators of Arkansas, or USAble Corporation that a practitioner is leaving a clinic.

If you have any questions regarding completion of this form, please contact Provider Enrollment at (501) 210-7050. If the practitioner is changing addresses or other data, he/she must also complete the Application for Provider Number /Change of Data Request form. If a practitioner is joining another clinic, he/she must complete an Authorization for Clinic Billing form.

To Provider Network:

Please be advised that the practitioner listed below has/will terminate his/her association with the following clinic/group and the clinic’s/group’s authorization to receive payment on behalf of the practitioner is terminated.