South Dakota Professional Provider Application

To submit an application from this site please use options # 1 or # 2:

• Option # 1
  Use your tab key to move to the next blank then key in your response. Once completed, please print a copy, sign and send or fax the application and all supporting materials to the address listed below.
• Option # 2
  Print off the application and fill out by hand, sign and send or fax to application and all supporting materials to the address listed below.
  

Provider Application and Credentialing, Station 165
Wellmark Blue Cross and Blue Shield of Iowa
636 Grand Avenue
Des Moines IA 50309-2565

or fax it to - 515-245-4884

All applications must be completed in their entirety and include all attachments requested. After we have reviewed your application, we may contact you for further information.

If you have any questions or need paper copies of these forms, please call Provider Application and Credentialing at 800-700-9137, or e-mail us at providercredentialing@wellmark.com.

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• South Dakota Professional Provider Application

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.