Member dismissal request form

This form is to be used by a Plan Provider’s office to request dismissal of a current Member assigned under a Sharp Health Plan policy.

* Required field.

Provider information

First Name

Last Name

Credentials

Provider NPI

Medical Group Name

Phone

Fax

Member information

Member First Name

Member Last Name

Member ID

92#######-## or S########

Date of Birth

Reason for dismissal

Select all applicable reasons

Irreparable damage to the physician-patient relationship

Financial

Fraud

Non-compliant

Abuse or threatening

Other...

Attachments

Please attach all supporting details and documentation. Supporting documentation may be in the form of copiesof medical records, office notes, etc., and may include pertinent dates, documentation of conversations, billing statements, documentation of previous attempts to educate the member regarding noncompliance with recommended treatment plans or office practices. Please attach all supporting details and documentation in either word, excel, or pdf format.

Note: Sharp Health Plan may request additional documentation from the plan provider. Requests must be fulfilled within five business days. If requests for additional documentation are not fulfilled within this timeframe, the dismissal request will be denied.

Attachments

Add another

E-Signature

I am confirming that all efforts to reassign this member to a provider within my plan medical group has been exhausted.*

I am requesting that this member be dismissed form my plan medical group's care and reassigned to another medical group within the Plan's network.*

Electronic signature

Title

Date