Provider Change Forms

All forms must be submitted within 30 days of the occurrence.

USE THIS FORMIF…
New Provider FormA new provider joins your practice
Provider Name ChangeA provider’s name changes
Provider Practice UpdateA provider moves to a new practice
Provider Exit FormAn existing provider leaves the practice and is no longer billing through the practice’s Tax ID #
New Practice / Location Form
  1. A new practice joins under an existing Tax Id # of a WKCC participant
  2. If you are an existing WKCC participant adding a new location to an existing Tax ID #
  3. You are a new practice requesting approval to participate in WKCC

Please also fill out the New Provider form for all of the providers in the new practice or location.

Practice / Location Exit FormA practice or location will no longer be participating with WKCC or under the practice’s Tax ID #
Portal User Termination FormA provider or practice administrator leaves and will no longer need access to the WKCC SharePoint Portal and/or Arcadia
Core Requirement Exemption FormYou need to request a core requirement exemption for one of your providers.

 

Portal Access