Provider Services Deactivation Form

Use the form below to deactivate individual providers from the various services for the ChartMaker Medical Suite. If deactivating an entire practice, please complete the ChartMaker Medical Suite Termination Checklist.

Provider Services Deactivation Form

Practice Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Fax Number
Authorized Office Contact Name*
First Last
Contact Email*
Name of Provider to be Deactivated:*
First Last Credential
DEA*
NPI*
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:
First Last Credential
2nd provider
DEA*
2nd provider
NPI*
2nd provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
3rd provider
DEA*
3rd provider
NPI*
3rd provider
I am requesting deactivation of the following service(s):
- Select All
- E-Prescribing
- Direct Messaging
- Electronic Case Reporting (eCR)
- EPCS (Electronic Prescribing Controlled Substances)
- ePA (Electronic Prior Authorization)
- PatientPortal
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
4th provider
DEA*
4th provider
NPI*
4th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
5th provider
DEA*
5th provider
NPI*
5th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
6th provider
DEA*
6th provider
NPI*
6th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
7th provider
DEA*
7th provider
NPI*
7th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
8th provider
DEA*
8th provider
NPI*
8th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
9th provider
DEA*
9th provider
NPI*
9th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
10th provider
DEA*
10th provider
NPI*
10th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
11th provider
DEA*
11th provider
NPI*
11th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
12th provider
DEA*
12th provider
NPI*
12th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
13th provider
DEA*
13th provider
NPI*
13th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
14th provider
DEA*
14th provider
NPI*
14th provider
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)
- Patient Portal
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY
Do you wish to deactivate another provider at this time?*
- Yes
- No
Name of Provider to be Deactivated:*
First Last Credential
15th provider
DEA*
15th provider
NPI*
15th provider
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
- ChartMaker® Mobile App
- eFaxing
- CDA/HIE (Health Information Exchange)
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.
MM slash DD slash YYYY

Provider Services Deactivation Form

Provider Services Deactivation Form

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