Provider Change Form

If you are changing both your Tax ID and your address, one of the following applications needs to be completed instead of this change form.


Practitioners Facilities and Entities

 

If you have questions about completing this form, e-mail us at providercredentialing@wellmark.com

 

*Required Fields

 

Requestor Information
*Requestor's First Name:
*Requestor's Last Name:
*Complete Phone Number:
*Requestor E-mail Address:
Provider Information
*Provider Name:
*Tax ID:
*Provider Clinic Name:
*Provider Address:
*Rendering NPI:
*Organizational NPI:
*Effective Date of Change: (mm/dd/yyyy)
 
Information to be Changed

NOTE: If you have more than one location or practice arrangement, you may need to complete a separate form for each site the change(s) affects. It is not necessary for you to complete a separate form for each network with which you are participating. One form will update your information for all networks.

 

*Select all that apply:
Address, Phone, Fax Change
Name Change
Tax ID Change
Organizational NPI Change
Provider/Group Cancellation
Specialty Change
Back-up Physician Information
Practitioner Payment Authorization
Directory Validation

 

Address, Phone, Fax Change

Complete the following to CHANGE address information. To ADD a practice location, an application must be submitted.

 


Practice address, phone, fax change only
Billing address change only
Both practice address, phone, fax, and billing change

 

Providers Affected By These Changes

Does this change affect all providers at this clinic location?
Yes
No

 


Indicate which provider(s) this change applies to:



















If there are more providers that this change applies to, list them here:

Name Change

Individual Name Change
Clinic Name Change (please fax a complete W-9 Form to 515-376-9035)

Prior Name
New Name
Indicate which location(s) this change applies to:

Providers Affected By This Change

Does this change affect all providers at this clinic location?
Yes
No


Indicate which provider(s) this change applies to:



















If you have more practitioners to cancel, list here:

Tax ID Change

Prior Tax ID (9 digits only; no dashes)
New Tax ID (9 digits only; no dashes)

W-9 Needed
I have already completed and faxed the W-9 Form on this date: (mm/dd/yyyy)
I will complete the W-9 Form and fax it to 515-376-9035

Providers Affected By These Changes

Does this change affect all providers at this clinic location?
Yes
No

 


Indicate which provider(s) this change applies to:



















If there are more providers that this change applies to, list them here:

Does this Tax ID Change also change the Organizational NPI used to bill for this TIN?
Yes
No


Organizational NPI Change

If you are reporting a new Individual NPI in order to bill Wellmark for claims and have not completed enrollment materials, please review Wellmark's Enrollment/Participation forms for an application.


If you are already enrolled and the only change to report is to add or change an organizational NPI to your existing location/TIN, continue with the change below.


If there is also a Tax ID change – please complete the Tax ID Change section of this form in addition to the NPI change

 

Prior NPI ID (10 digits only; no dashes)
New NPI ID (10 digits only; no dashes)

Cancellation

Individual Provider Cancellation
Group Cancellation (affects multiple providers under one TIN)

Clinic Name:

Address:

City, State, Zip:

Reason:

No longer here; if known, where will provider be practicing:
Retired
Deceased
License revoked
Moved out of state

Cancel all practice locations for this practitioner under this TIN?
Yes
No

 


Indicate which practice location(s) will be cancelled:



















If you have more practice locations to cancel, list them here:

Date Clinic Closed: (mm/dd/yyyy)

Cancel all practitioners who practice at this location under this TIN?
Yes
No

 


Indicate which practitioner(s) will be cancelled:



















If you have more practitioners to cancel, list here:

Specialty Change

Specialty Change
Add a Secondary Specialty

Previous Specialty
New Specialty
Secondary Specialty

 

I wish to be listed in the Provider Directory as a:
Primary Care Physician
Specialist
PCP-OB/GYN


Indicate which location(s) this change applies to:

 


Addition/Change to Backup Physician Information

If your back-up arrangements are different by locations, please submit a separate change request for each location that is different.

Practitioners who currently provide backup coverage for you:

Back-up Physician #1

Name


Address


Specialty


NPI


Effective Date (mm/dd/yyyy)

Back-up Physician #2

Name


Address


Specialty


NPI


Effective Date (mm/dd/yyyy)

Back-up Physician #3

Name


Address


Specialty


NPI


Effective Date (mm/dd/yyyy)

Back-up Physician #4

Name


Address


Specialty


NPI


Effective Date (mm/dd/yyyy)

If you have more back-up physicians, list them here including name, address, specialty, NPI, and effective date for each:

Practitioner Payment Authorization

Complete the Practitioner Payment Authorization form in order for Wellmark to make payment to the clinic on behalf of the practitioner (required for clinics with two or more practitioners).

 


Directory Validation

Directory Validation Email

Languages Spoken

Hospital Admitting Privileges

  • Required for all MD and DO specialties EXCLUDING Allergy, Anesthesiology, Dermatology, Emergency Medicine, Genetics, Occupational Medicine, Pathology, Psychiatry, and Radiology
  • Required for PA’s, ARNP’s, and CNM’s acting in a PCP or PCP-OB/GYN role
Certifications and Accreditations

To update age limitations and accepting new patients, select the Address, Phone, Fax change option above.



Directory Validation Email (used to verify your information in the Wellmark Directory for all practice locations)


List languages other than English that you speak


List Hospital Name, City, and State where you have admitting privileges


Certifications and Accreditation

Practioners
  • Provider Boards - applicable for MD, DO, DPM, DC, DDS Oral Pathology, and Oral Surgery
  • Certifications - applicable for PhD, QMHP, and Registered Dietitian
Facilities and Entities

Board or Certification Name
Certification Number
Original Certification Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

Board or Certification Name
Certification Number
Original Certification Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

Board or Certification Name
Certification Number
Original Certification Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

For additional certifications, list board or certification name, specialty, certificate number, original certificate date, and expiration date below.


Accrediting Body
Certification or Accreditation Number
Last Review or Renewal Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

Accrediting Body
Certification or Accreditation Number
Last Review or Renewal Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

Accrediting Body
Certification or Accreditation Number
Last Review or Renewal Date
(mm/dd/yyyy)
Expiration Date
(mm/dd/yyyy)

For additional certifications, list accrediting body, certificate or accreditation number, last review or renewal date, and expiration date below.



Terms & Electronic Signature

This is an electronic Wellmark, Inc. Provider Change Form (Form). I understand that the information entered on the Form that subsequently if found to be false could result in immediate dismissal from any Wellmark, Inc. network. I hereby attest that the information contained on this Form is true, accurate, and complete. I authorize release of all information as may be required by Wellmark, Inc. to process this Form. By electronically signing this Form I authorize Wellmark, Inc. to release this information to Wellmark, Inc. affiliates and subsidiaries. My electronic signature on this Form does not constitute a contract with Wellmark, Inc.


I understand by clicking on the check box by the signature line, typing my name on the signature line, typing the date on the date line and clicking the submit button I am in effect signing this Form for myself and attesting to all the information herein (OR) I am in effect signing this Form and hereby attest that I have the authority on behalf of the above named provider(s) to complete this Form and I am attesting to all the information herein.

I agree to terms above Type your Name:
Date:

 

Submit Your Changes

  • Depending on our specific needs relative to the change(s) you are making, we may have to contact you for additional information.
  • Upon submission you should receive via e-mail, a carbon copy of the change form so that you have record of completing it.
  • You may also be notified via e-mail upon completion of your requested change.

 

    

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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.
 
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