Pharmacy Contract Termination Form
Use this form to submit a pharmacy contract termination request with the contract details, termination timing, and requester contact information.
Contract Identification
Contract or Account Reference
*
Pharmacy or Business Name
*
Contract Type
*
Please Select
Retail Pharmacy Agreement
Mail-Order Pharmacy Agreement
Provider Network Agreement
Pharmacy Services Agreement
Rebate Agreement
Other
Requested Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Termination Details
Reason for Termination
*
Contract completed
Service no longer needed
Relocation
Provider change
Billing dispute
Service quality concerns
Other
Request Timing
*
Immediate
Scheduled
Requested Final Service Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Termination Note / Special Instructions
Requestor Information
Requestor full name
*
First Name
Middle Name
Last Name
Job title or role
*
Work email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Termination Request
Should be Empty: