Provider Change Form

Instructions:

  • If you are changing both your Tax ID and your address, an application needs to be completed instead of this change form. Please refer to the Enrollment/Participation forms section of the web for the application.
  • Please complete all sections that apply to the requested change.
  • If you have more than one location or practice arrangement you may need to complete a separate form for each site that 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.
  • 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.
  • If you have questions about completing this form, please e-mail us at providercredentialing@wellmark.com
  • If you bill electronically, please fax a copy of this form (using File/Print) to EDS/EC Solutions at 1-800-691-1038

*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:
*Billing NPI:
*Effective Date of Change:
 
Information to be Changed
*Select all that apply:
Address Change – including phone and fax numbers
Name Change
Tax ID Change
Provider/Group Cancellation
Specialty Change

Address Change

Physical address change only
Billing address change only
Both physical address and billing change

 

Will group billing affiliation change?
Yes
No


Name Change

Individual Name Change
Clinic Name Change (please fax a complete W-9 Form if name change is a result of a TIN change)

FROM
TO
Indicate which location(s) this change applies to:

Tax ID Change

FROM (numeric characters only; no dashes)
TO (numeric characters only; no dashes)

I have already completed and faxed the W-9 Form on this date:
I will complete the W-9 Form and fax it to 515-376-9035


Cancellation

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

LOCATION

Clinic Name:

Address:

City, State, Zip:

REASON (please include dates in field provided)

No longer here,
Retired,
Deceased,
License revoked,
Moved out of state
Other,

If reason above is "no longer here", where will provider be practicing in the future (if known)?

Clinic Name:

Address:

 

Specialty Change

Previous Specialty
New Specialty

I wish to be listed in the Provider Directory as a:
Primary Care Physician
Specialist
Co-Care

Indicate which location(s) this change applies to:

    

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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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