Name of practitioner leaving:
    Last: *
     
    First: *
     
    Middle Initial:
    Degree: *
     
When will practitioner be leaving? *
  
What location(s) does practitioner currently provide services at? *
 
(Practicing Site Name/City)
If practitioner is a Primary Care Physician, who will be taking members currently assigned to practitioner?

If practitioner is a Specialist, who will be taking referrals that were assigned to practitioner?
How will members be notified of this change? *
 
If this was the only practitioner at the site, will practitioner be replaced? *
   
If so, when?
 
Where will this practitioner be going (required by Wis. Law)? *
 
(Practice Site Name/City)
Where can practitioner be contacted in the future?
Phone:
 

Why is practitioner leaving? * (Must check one and complete the applicable questions.)   
  • What new location will practitioner be providing services at?    
  • When will practitioner start at this new location?     
  • Will practitioner's hospital privileges change with new location change?      
    If yes, new privileges at:    

  • Is there a "no-compete" clause in your contract with practitioner?      
  • If yes, does new location meet requirement and therefore practitioner can practice without being in breach of your contract?      
  • When will practitioner start at this new location?     

 When does practitioner plan to return to work?       
   

Please remember that if practitioner is moving to a new location in Wisconsin or the area surrounding Wisconsin, the practitioner will be obligated to see members under this contract's obligations and reimbursement.

  • Primary Care Physicians are obligated for 1 year after the termination date.
  • Specialists are obligated for 90 days after the termination date. 

* Indicates a required field.