IPA NY Opt-Out Form

  • OPT-OUT FORM

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  • 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.

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