Termination Form
Employee Name:
*
First Name
Last Name
Employee's Personal Cell Phone Number:
*
Please enter a valid phone number.
Employee's Personal Email:
*
example@example.com
Job Title
*
Please Select
Accounts Receivable Manager
Accounts Receivable Specialist
Billing Manager
Billing Specialist
Business Analyst
Case Manager
Chief Executive Officer
Chief Medical Officer
Chief Operating Officer
Chief People Officer
Clinical Informatics Director
Co-Responder Crisis Interventionist
Controller
Coordination and Engagement Liaison
Credentialing Specialist
Crisis Clinical Supervisor
Crisis Counselor
Crisis Counselor Telehealth
Crisis Operations Coordination & Engagement Liaison
Crisis Operations Manager
Crisis Operations Specialist - Day
Crisis Operations Specialist - Night
Crisis Regional Director
Crisis Schedule Coordinator
Crisis Staffing Specialist
Crisis Staffing Specialist Telehealth
Director of Quality and Informatics
District Clinical Manager
District Clinical Manager Telehealth
Executive Assistant
HRR Regional Manager-BTMC
Human Resources Generalist
IT Reporting Specialist
IT Specialist
Information Systems Manager
Insurance Verification Specialist
Integrated Case Manager
Medical Assistant
Medical Records Specialist
Outpatient Clinical Director
Outpatient Clinical Supervisor
PNP
Payment Posting Specialist
Public Safety Liaison
Public Safety Outpatient Counselor
Public Safety Services Manager
QI Coordinator
Revenue Recovery Specialist
SMI Evaluations Coordinator
SMI Evaluations Manager
SMI Evaluator
Senior Accountant
Senior Billing Specialist
Senior Crisis Operations Manager
Senior Director of Community Programs and Partnerships
Senior Executive Assistant
Senior Revenue Cycle Manager
Shared Services Manager
Site Administrator
TCP Caseload Support Coordinator
TCP Counseling Manager
Transitional Care Counselor
Vice President Public Safety
Department
*
Please Select
Accounting
Administration
Billing
Credentialing
Crisis
Finance
Human Resources
Informatics
Public Safety
Quality Management
Revenue Management
SMI
Transitional Care
Is the employee independently licensed?
*
YES- the employee is independently licensed
NO- the employee is NOT independently licensed
Is the employee a supervisor?
*
Yes
No
Please list the employee's direct reports and who will now be their new supervisor:
Termination/ CPR System Disconnection Date:
*
-
Month
-
Day
Year
The termination and system disconnection date need to coincide.
Is the employee's last day worked (performed any work duties - emails, billing, etc.) the same as their termination date?
*
Yes
No
Last Day Employee Performed Work
*
-
Month
-
Day
Year
Date
Employee termination is:
*
Voluntary
Involuntary
Reason for Employee Termination (Voluntary)
*
Please Select
Did not return from Leave
Health Reasons
Mutual Agreement (Personal, Voluntary Quit in Lieu of Discharge)
Retirement
Seek or Accept Other Employment
Transfer/ Promotion
Working Conditions/ Job Dissatisfaction
Deceased
Other
Reason for Employee Termination (Involuntary)
*
Please Select
Attendance/ Absenteeism/ Tardiness (Failure to Report for Work/Abandonment, No-show, Attendance.)
Contract Expired
Criminal Acts/ Property Damage (Felony/Misdemeanor, Violation of Law/Criminal Acts, Property Damage.)
Dishonesty/ Theft
Drugs/ Alcohol
Failed to Meet Performance/ Policy Standards (Not Qualified/ Inadequate Performance, Failed to Follow Instructions/Policy/Contract, Failed Employment Requirements)
Lay Off/ RIF/ Lack of Work/ Reorganization
Misconduct (For any misconduct not captured in other categories (e.g., insubordination, harassment))
Other
Other
*
Employer statement:
Can the employee be rehired?
*
Yes
No
The reason why he/she cannot be hired again:
Does the employee have any CPR IT equipment/property to return? (please list the equipment)
*
Does the employee have an admin building access and/or admin parking access card?
*
Yes
No
It is imperative you coordinate with IT and the departing employee an equipment drop off time. All appointments below are open for Equipment Drop-Off. Note: The calendar slot labels are for IT use only.
Please confirm Equipment Drop-Off date & time chosen above:
*
In the event the employee leaves the equipment with the manager, please reach out to IT and provide details.
Any related documents about termination (please upload resignation letter):
*
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Supervisor Name:
*
First Name
Last Name
Supervisor's CPR Email:
*
example@example.com
Supervisor Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: