Provider Services Deactivation Form Provider Services Deactivation Form Please select ONE option from below:*Note: If the entire practice and its providers will no longer be using these services from STI, please select the second option. I would like to deactivate a provider(s) from these services I would like to deactivate my practice from these services I am requesting deactivation from the following service(s): Select All E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Practice Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Fax NumberAuthorized Office Contact Name* First Last Contact Email* Name of Provider to be Deactivated:* First Last Credential DEA*NPI*Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Group NPIThe Group NPI is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start date of deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated: First Last Credential 2nd providerDEA*2nd providerNPI*2nd providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 3rd providerDEA*3rd providerNPI*3rd providerI am requesting deactivation of the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start date of deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 4th providerDEA*4th providerNPI*4th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 5th providerDEA*5th providerNPI*5th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 6th providerDEA*6th providerNPI*6th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 7th providerDEA*7th providerNPI*7th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 8th providerDEA*8th providerNPI*8th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 9th providerDEA*9th providerNPI*9th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 10th providerDEA*10th providerNPI*10th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 11th providerDEA*11th providerNPI*11th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 12th providerDEA*12th providerNPI*12th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 13th providerDEA*13th providerNPI*13th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 14th providerDEA*14th providerNPI*14th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) Patient Portal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY Do you wish to deactivate another provider at this time?*YesNoName of Provider to be Deactivated:* First Last Credential 15th providerDEA*15th providerNPI*15th providerI am requesting deactivation from the following service(s): E-Prescribing Direct Messaging Electronic Case Reporting (eCR) EPCS (Electronic Prescribing Controlled Substances) ePA (Electronic Prior Authorization) PatientPortal Provider Complete (Electronic Billing) ChartMaker® Mobile App eFaxing CDA/HIE (Health Information Exchange) Provider Tax IDThe Tax ID is required when deactivating Provider Complete.Have you ported your fax number back to your office?*When deactivating efaxing, please check all that apply. We have contacted our phone company to port our fax number back. We are using the Updox virtual fax number. Reason for deactivating eFaxing (Updox):*Start Date of Deactivation:*Please select a date for your existing services to be deactivated. Date Format: MM slash DD slash YYYY