IPA NY Opt-Out Form

  • OPT-OUT FORM

  • Date of Submission*
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  • Request Type*
  • Action Requested*

  • OPT-OUT FORM

    All providers in a given group and Tax ID need to maintain consistent participating or nonparticipating status with all plans.

  • Provider List

  • By selecting 'Opt Out', you are electing to not to participate with the plan. Otherwise, you will be enrolled in all that states 'Included'.

    Please note: Below includes where payer contract excludes certain Specialty types

  • Please OPT OUT our practice from the following plans (Check all that apply):

     

    Note: If you are OPTED IN for a payer, it means your panel is open to accepting new patients and is directory available. 

  • MEDICAID PLANS REQUIRE YOU TO BE LICENSED WITH STATE MEDICAID. YOU WILL NOT BE ABLE TO PARTICIPATE WITH MANAGED MEDICAID IF YOU ARE NOT PARTCIPATING; WITH STATE MEDICAID. PLEASE OPT OUT OF THOSE PLANS. IF YOU DO NOT HAVE A MEDICARE NUMBER, YOU  WILL NOT BE ABLE TO PARTIPATE WITH PLANS THAT ONLY OFFER MEDICARE. PLEASE OPT OUT OF THOSE PLANS.

  • Aetna/First Health (Commercial/Medicare Number Required)*
  • AmidaCare NY (Medicare/Medicaid Number Required) Exclusions: Chiropractor, Behavioral Health*
  • CenterLight (Medicare/Medicaid Number Required)*
  • Centivo – (Commercial) Exclusions: Physical Therapy, Occupational Therapy, Chiropractor, Acupuncture*
  • Cigna (Commercial) Exclusions: Chiropractor*
  • Emblem/GHI HMO and PPO/HIP Commercial/HIP SelectCare & Millenium/NY/HIP Medicaid/ HIP Medicare (Medicare/Medicaid Number Required)*
  • Empire BCBS (Commercial/Medicare Number Required) Exclusions: Chiropractor*
  • Empire BCBS HealthPlus (Medicaid/Duals- Medicare/Medicaid Number Required) Exclusions: Chiropractor, Ophthalmology, Optometry*
  • Hamaspik (MLTC/Medicare/Medicaid Number Required)*
  • HealthFirst (Medicare/Medicaid Number Required) A valid Medicaid number is required for enrollment with Healthfirst. Providers without a Medicaid number are not eligible to enroll*
  • HealthSpring MA (Medicare Number Required)
  • Humana Medicare Advantage (Medicare Number Required)*
  • Claritev (Formerly known as Multiplan)/PHCS/Beech Street (Commercial/Workers Comp) Beech St sep*
  • Oscar (Commercial) Exclusions: Behavioral Health*
  • Wellcare (Medicare ONLY- Medicare Number Required)*
  • UnitedHealthCare (Commercial ONLY-Medicare/Medicaid through UHC directly NOT the IPA) Included Counties: Nassau, Suffolk, 5 Boroughs, Westchester, Putnam, Sullivan, Orange, Rockland Dutchess and Onondonga Exclusions: Behavioral Health*
  • VillagecareMax (Medicare/Duals/Medicaid/MLTC- Medicare/Medicaid Number Required) Exclusions: Anesthesiology, Behavioral Health, Critical Care, Emergency Medicine, Hospitalist, Pathology, Optometrist, PA, RN, LPN, Pediatrics; Radiology*
  • Today's Date*
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