Deactivate Provider Form

Deactivate Provider Request Form

Deactivate Provider Request Form

Please fill out all required sections on this form and submit

MEDENT Account Number:*

Directory (if multiple directories):

Last Day At Practice:

Has the provider left practice permanently?*

Yes
No

If No - please explain

Provider#:*

Provider Name:*

*Reminders: Deactivate Provider as User: Your office must deactivate the provider from the user file. CCS cannot remove users. There may be open items such as triages, todos, documents or default users that need to be addressed within the office.

Charges for Deactivated Provider: Charges can still be entered for a Deactivated provider, the charge date must be prior to the deactivation date. To select a Deactivated provider: In the doctor # field of charge entry click the drop down or F1 to view full list > click on the Menu icon (top right corner of screen) Show Deactivated > Select the Deactivated Provider

Is this Provider setup as a 'Supervising Doctor' in the Doctor Setup for NP/PA, etc.?*

Yes
No

If Yes, please indicate who the new supervising doctor will be for the NP/PA, etc.. that this deactivated doctor currently supervises

Scheduling Information:

Office Appointments:If the provider has a schedule with future appointments, these appointments will need to be moved and the schedule removed. Will you need assistance moving patients and removing the deactivated providers schedule?*

Yes
No

Surgical Book Planner: If the provider has a surgical book planner, surgical appointments in the future will need to be moved to another provider. Will you need assistance moving patients to another provider?*

Yes
No

RevSpring Appointment Reminders: Your office will need to remove the deactivated provider from your RevSpring appointment reminder setup. If your office is setup for reminders for all providers, no change is necessary. If you are setup for selected providers, you will need to remove the provider from the setup area. Will you need assistance removing a provider from appointment reminders?*

Yes
No

Interfaces & Labs:

Interfaced Labs: If your office is using an interfaced lab clearinghouse, will your office be expecting lab results to come through for this provider? It is very important to discuss this with the person in your office who is responsible for lab results coming in electronically.*

Yes - Your office will continue to be setup for an additional 30 days from the date we process this request.
No

***** For electronic lab results, if you find that you are missing any results for a provider being decativated you must contact the facility to receive a hard copy

Interface HIE/RHIO Radiology and Transcription Results: If your office is using an HIE/RHIO document import interface will your office still be expecting results to come in via the interface for this provider? It is very important this is discussed in your office with the person responsible for processing the HL7 documents that are coming in electronically.*

Yes - Your office will continue to be setup for an additional 30 days from the date we process this request.
No

Special Requests:

***** You will also need to reach out to the entity that you are receiving results from to provide them with a stop date for the provider.

THIS FORM NEEDS TO HAVE THE CONTACT AND SIGNATURE SECTION COMPLETED FOR ALL PROVIDERS BEING DEACTIVATED. IF IT IS NOT COMPLETED, WE CANNOT DEACTIVATE THE PROVIDER. WHICH MAY CAUSE YOUR OFFICE TO CONTINUE TO BE BILLED FOR SERVICES AND MODULES FOR THIS PROVIDER. IT CAN ALSO CAUSE YOUR OFFICE TO CONTINUE TO GET LAB RESULTS, DOCUMENTS AND ORDER RESULTS ELECTRONICALLY FOR THIS PROVIDER IN ERROR

Please have the practice owner or practice administrator sign off on this form.

Authorized Name:*

Signature (by checking this box you are signing this document)*

Contact Person:*

Contact Email:*

Phone:* Ext:

Provider will be deactivated within 48 hours of received request. Verification that provider has been removed can be confirmed by reviewing the Doctor Setup for active providers.