Skip to Main Content

PMP Term

Primary Medical Provider (PMP) Name

Practitioner will be termed from all locations associated with this TIN
Please write Ambetter Only in this box if not enrolled with IHCP

Service Location Address

Programs to Term (choose all that apply) required *

Update Requested By:

Move Members To (choose one): *

If the accepting provider is not a current MHS panel holding PMP, and/or the panel size or age restrictions cannot accommodate individual members being assigned to the requested provider, the members will be auto assigned.

Last Updated: 01/24/2024