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
Tax ID Change
Organizational NPI Change
Back-up Physician Information
Practitioner Payment Authorization
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.
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