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