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Enrollment of Practitioners

Apply for Participation: Submitting Forms

(continued from Enrollment Forms or Participation Agreements)

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Step 9) Providers who are interested in obtaining a provider guide may download the provider guides, or complete a Provider Forms Order Form.

Step 10) Package all documents and any other documentation requested on the application and return them to:

PO Box 14509
Wellmark Blue Cross and Blue Shield of Iowa
636 Grand Avenue
Des Moines, IA 50309

Please review the following checklist to assure all the necessary documentation is being submitted.

• Application (one of the following)
  • Professional Provider Application, or the
  • Iowa Statewide Universal Practitioner Application

  Make sure the application is signed and all copies of any requested additional documents are included. Wellmark will not process your application unless at least the following information is submitted:

  • Name
  • Title
  • Practice Address
  • Beginning Practice Date
  • Date of Birth
  • Social Security Number
  • Federal Tax ID Number
  • License Number
  • Specialty
  • Liability Insurance Attestation
  • Hospital Privileges
  • Education
  • Training
  • Employment History
  • Back-up Information

• Supplemental application documents as defined on the application
• W-9 Federal Tax Information Form
• Electronic Claims Form
• TRICARE Behavioral Health provider forms

Thank you for your interest in serving Wellmark customers. For questions during the enrollment process, please contact Provider Application and Credentialing by e-mail at providercredentialing@wellmark.com or call us at 1-800-708-1342 or 515-245-5100.

Copyright© 2008 Wellmark, Inc. All Rights Reserved.
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.