Member Dismissal Form "*" indicates required fields Email*Please enter your gracelight.org email address. Email address is not correct. Go back and enter a valid @gracelight.org email address.Provider Requesting Dismissal:*Patient Name*Patient MRN*Staff Submitting this Form*Form Submission Date*Reason for Request:* Noncompliance Irreparable damage to the physician-patient relationship Fraud Abuse or threatening Disruption in Operations REASON FOR REQUEST:*Please be as specific as possible with the following: [1] please state your concern; [2] date(s) of event; [3] time of event; [4] staff member(s) involved, and [5] location of event. Use the other side of this form if you need more room.Please attach all supporting details and documentation. Supporting documentation may be in the form of copies of medical records, office notes, etc., and may include pertinent dates, documentation of conversations, documentation of previous attempts to educate the patient regarding noncompliance with recommended treatment plans or office practices. Please attach all supporting details and documentation in either word, excel, or pdf format and delivered to the Health Center Manager in an envelope marked Confidential. Note: The QCO and/or Determination Committee may request additional documentation from the Provider and/or staff. Requests must be fulfilled within five business days. If requests for additional documentation are not fulfilled within this timeframe, the dismissal request will be denied.File Drop files here or Select files Max. file size: 32 MB. SignatureCAPTCHA
