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Panel Release Form - Providers - Prestige Health Choice Panel Release Form

Panel Release Form - Providers - Prestige Health Choice Panel Release Form 2026

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The document is a Panel Release Form used by providers to formally terminate a member from their practice. It outlines the necessary information required for the termination, including reasons for release, provider details, and attestation of compliance with specific procedures. The form emphasizes the need for documentation of attempts to maintain the physician-patient relationship and ensures that members are assisted in finding new providers.

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Click ‘Get Form’ to open the Panel Release Form in the editor.
Begin by entering your Provider name and Provider ID# in the designated fields at the top of the form.
Fill in your Provider address completely to ensure accurate communication.
List the Member or family name(s) along with their corresponding ID numbers in the provided sections.
Select a reason for release by checking one of the options provided. If applicable, attach any necessary documentation or narratives as instructed.
In the attestation section, sign and date the form to confirm that all information is true and complete.
Ensure you affirm all conditions listed regarding attempts to salvage the physician-patient relationship and provide any supporting documentation required.

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