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

Please complete all sections applying to the requested change; you may be contacted for additional information. If you bill electronically, please fill out this form and fax to EDS/EC Solutions at 800-691-1038.

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.

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

*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

Address, Phone, Fax Change

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 if name change is a result of a TIN change)

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).

 


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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