<p> Center of Occupational Health & Education (COHE) Program Attending Provider in the Program (APP) - Notice of Program Disenrollment </p><p>Provider Name L&I Provider Number(s)</p><p>Enter Name Enter Number(s)</p><p>Name of Clinic/Group, if applicable Group Number(s), if applicable</p><p>Enter Name Enter Number(s)</p><p>Name of person making disenrollment request from theDate clinic/group Enter Date Enter Name</p><p>Last day of COHE Advisor participation: Last Participation Date</p><p>Please select reason for Advisor disenrollment:</p><p>☐ Left group/clinic/facility </p><p>☐ No longer practicing (e.g., retired) </p><p>☐ Still practicing, but electing disenrollment. List reason (optional): Enter reason</p><p>☐ Joining another COHE</p><p>☐ Other: Enter other reason</p><p>COHE representative submitting request to L&I: Enter Name</p><p>Completed forms can be faxed to 360-902-6515 or emailed to [email protected]. </p><p>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 </p>