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Terms

What do you want to do? required * Term a PCP Term a Specialist Term multiple PCPs Term multiple Specialists

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Term a PCP

Choose all applicable networks required * Ambetter (Exchange) SilverSummit (Medicaid) Wellcare by Allwell (Medicare)

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PCP First Name *

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PCP Last Name *

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PCP NPI # *

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TIN (last four digits only) *

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Group/Facility Name *

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Group/Facility NPI # *

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Practitioner will be termed from all locations associated with this TIN and Group NPI

Date Term Effective *

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mm/dd/yy

Term Reason *

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Other

Move Members to required * Auto-assignment Provider

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Provider First Name *

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Provider Last Name *

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Provider NPI # *

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Where can we request medical records from? *

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Update Requested By

Requestor *

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Requestor's Email Address *

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Comments

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Term a Specialist

Choose all applicable networks required * Ambetter (Exchange) SilverSummit (Medicaid) Wellcare by Allwell (Medicare)

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Specialist First Name *

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Specialist Last Name *

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Specialist NPI # *

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TIN (last four digits only) *

Error: This field is required.

Group/Facility Name *

Error: This field is required.

Group/Facility NPI # *

Error: This field is required.

Practitioner will be termed from all locations associated with this TIN and Group NPI

Date Term Effective *

Error: This field is required.

mm/dd/yy

Term Reason *

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Other

Where can we request medical records from? *

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Are members being refererred to a SSHP Specialist required * Yes No

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If yes, who are they being referred to?

Specialist First Name *

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Specialist Last Name *

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Specialist NPI # *

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Update Requested By

Requestor *

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Requestor's Email Address *

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Comments

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Term Multiple PCPs

Choose all applicable networks required * Ambetter (Exchange) SilverSummit (Medicaid) Wellcare by Allwell (Medicare)

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TIN (last four digits only) *

Error: This field is required.

Group/Facility Name *

Error: This field is required.

Group/Facility NPI # *

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SSHP Roter Template (Excel)
(Template revised in 12/2024)

Provider Roster Upload *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Where can we request medical records from? *

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Update Requested By

Requestor *

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Requestor's Email Address *

Error: This field is required.

Comments

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Error: Please add a Captcha.

Term Multiple Specialists

Choose all applicable networks required * Ambetter (Exchange) SilverSummit (Medicaid) Wellcare by Allwell (Medicare)

Error: This field is required.

TIN (last four digits only) *

Error: This field is required.

Group/Facility Name *

Error: This field is required.

Group/Facility NPI # *

Error: This field is required.

SSHP Roster Template (Excel)
(template revised in 09/2024)

Provider Roster Upload *

Error: File upload is required.

Items in the trash will be permanently removed after 30 days.

Where can we request medical records from? *

Error: This field is required.

Are members being refererred to a SSHP Specialist required * Yes No

Error: This field is required.

If yes, who are they being referred to?

Specialist First Name *

Error: This field is required.

Specialist Last Name *

Error: This field is required.

Specialist NPI # *

Error: This field is required.

Update Requested By

Requestor *

Error: This field is required.

Requestor's Email Address *

Error: This field is required.

Comments

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1-844-366-2880

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To report suspected fraud, waste, abuse or improper payment call 1-866-685-8664.