Loading
Get Voluntary Termination Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Voluntary Termination Form online
The Voluntary Termination Form is used to officially terminate your provider agreement with Ohio Medicaid. This guide provides a step-by-step approach to completing the form online, ensuring that you understand each section and field.
Follow the steps to complete your Voluntary Termination Form online.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- In the 'Date' field, enter the current date when you are submitting the form.
- Fill out the address information in the 'To' section, which should state 'Bureau of Provider Services, Network Management Section'.
- In the 'From' section, write your Provider Number in the designated field.
- Print your provider name clearly in the provided space under 'Provider Name'.
- Complete your address by filling in the fields following 'Address:', ensuring all details are accurate.
- In the statement provided, print your name in the field labeled 'I, (print your name)' to confirm your commitment to voluntarily relinquishing your independent provider number.
- Review the statement regarding the understanding of the implications of terminating your provider agreement.
- Sign the form in the designated 'Signature' section to validate your request.
- Enter the date of your signature in the 'Date' field next to the signature area.
- Once you have filled out the entire form, save your changes, and if needed, download, print, or share the form for submission.
Complete your Voluntary Termination Form online today to ensure your agreement is processed accurately.
It's always better for your reputation if you resign, because it makes it look like the decision was yours not theirs, Levit says. But if you resign, you may not be entitled to the type of compensation you would receive if you were fired.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.