Center of Occupational Health & Education (COHE) Program

Center of Occupational Health & Education (COHE) Program Attending Provider in the Program (APP) - Notice of Program Disenrollment

Provider Name L&I Provider Number(s)

Enter Name Enter Number(s)

Name of Clinic/Group, if applicable Group Number(s), if applicable

Enter Name Enter Number(s)

Name of person making disenrollment request from theDate clinic/group Enter Date Enter Name

Last day of COHE Advisor participation: Last Participation Date

Please select reason for Advisor disenrollment:

☐ Left group/clinic/facility

☐ No longer practicing (e.g., retired)

☐ Still practicing, but electing disenrollment. List reason (optional): Enter reason

☐ Joining another COHE

☐ Other: Enter other reason

COHE representative submitting request to L&I: Enter Name

Completed forms can be faxed to 360-902-6515 or emailed to [email protected].

This notification is for COHE Program disenrollment only. If the provider separated employment with the organization, and you would like to inactivate the account, you must contact Provider Credentialing & Compliance at: 360-902-5140 or complete the Provider Payment Account Change Form which you may fax to: 360-902-4484