PatientPortal Practice Deactivation Form - STI

1-800-487-9135 sales@sticomputer.com

To deactivate your PRACTICE from PatientPortal, please complete the following PatientPortal Deactivation Form.

IMPORTANT: If you wish to deactivate an INDIVIDUAL PROVIDER, you will need to fill out our Health Portal Deactivation form.

Practice Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Deactivation Date*
Date Format: MM slash DD slash YYYY
Reason for deactivating the PatientPortal:*
Contact Name*
First Last
Contact Email*