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Specialist Term




Specialist 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)*

Update Requested By:





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: 08/24/2021