Remove a Provider From Your Group

Provider Removal Change Form 

Let us know when your information changes so that we may update our system. This form is intended for use by established contracted groups who need to notify Samaritan Health Plans of changes to their group.

If you are interested in contracting with us, let us know you’d like to join our network.

Additional steps you should take:

• For questions about this form, please call Provider Services at 541-768-5207 or 888-435-2396, 8 a.m. to 6 p.m., Mon. through Fri.
• Documentation (such as W-9s) can be faxed to Provider Services at 541-768-9364.

Note: All provider and demographic changes must be reported to us within 30 days.