Termination Request Form

By filling out and submitting this form you are requesting termination of your Contract without cause. Please refer to Section 8.2 of your contract which requires 90 day notice for Termination Without Cause. 
If you are wanting to terminate specific Tax IDs while retaining your contract for a current or new Tax ID, please return to the Provider Portal and submit a demographic change.

Provider Information
Please enter email where you would like the termination confirmation to be sent.
Please submit a list of your current members in care or members impacted by this termination per Contact Section 8.4 Obligations Following Termination and include Member ID and DOB.
Please Note: Lucet will notify you of the actual termination date if different from your requested date based on the contractual terms in Section 8.2 regarding 90 day notice or a mutually agreeable date based upon your request. 
I attest that I am the contracted Provider who entered into the New Directions Provider Agreement and I have the legal authority to complete this form. I attest that this information is true, accurate and complete to the best of my knowledge. I understand that any falsification, omission or concealment of material fact may subject to administrative, civil or criminal law.