Service Centers // Provider Center

Remove Location to Existing Ancillary Facility

NOTE: Please be sure to include all locations where provider is currently listed to ensure they are removed from the directory.

Group Information

Required
Required
Required
Required
Required

Completed By

Required
Required
Required
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 1

Required
Required
Required
Example: (555) 555-5555 or 555-555-5555
Required
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 2

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 3

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 4

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 5

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 6

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 7

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 8

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 9

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555

Remove This Location: Location 10

Example: (555) 555-5555 or 555-555-5555
Example: (555) 555-5555 or 555-555-5555
If you need to remove more locations than permitted on this form, please complete another form for the remaining locations.