1/22/2024
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Posted by Provider Relations
In an effort to streamline provider termination submissions to Fidelis Care, we have created a new electronic Termination Request Form for providers to use. Please use this form to submit any requests to terminate a provider from a TIN. In order to expedite the changes requested, all fields on the form are required. If not complete, the request will be delayed.
Once completed, the form can be submitted electronically to SMProviderAttestationUpdates@fideliscare.org. In the subject line of the email, please enter Termination Request for "Your Provider/Group Name" in "Your County" (i.e. Termination Request for ABC Healthcare Group in Ontario County).
Please remember, provider termination notices should be submitted to Fidelis Care no later than 60-days prior to the effective date.
Please note: This form should not be used by delegated credentialing entities. Delegated groups should continue to submit termination requests through the established process.
If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.