Non-Delegated Practitioner Voluntary Termination Form

To provide Meridian Notice of Voluntary Termination of a practitioner, please download and fill the Termination Form Template below, and upload to the form.

Termination Form Template (Excel | .xlsx)

Voluntary Termination Form Upload *

In order to meet Federal and State contractual requirements to notify members of a provider termination, Meridian is requiring that providers submit a voluntary termination form at least 60 calendar days before the termination effective date. For more information, please review our provider manual.

Please attest to the following:

I understand that in order to provide 60-day prior notice to affected members my effective date of voluntary termination must be at least 60 calendar days from notification.

Termination requested by:

First Name: *

Last Name: *

Contact Email: *

Contact Phone Number *

Tax ID Number *

Last Updated: 09/25/2026