Provider Change Forms

All forms must be submitted within 30 days of the occurence.

USE THIS FORM IF...
New Provider ​A new provider joins your practice
Provider Exit ​An existing provider leaves the practice and is no longer billing through the practice’s Tax ID #
​New Practice / Location
  1. A new practice joins under an existing Tax Id # of a WKCC participant
  2. If you are an existing WKCC participant adding a new location to an existing Tax ID #
  3. You are a new practice requesting approval to participate in WKCC
Please also fill out the New Provider form for all of the providers in the new practice or location.
Practice / Location Exit ​A provider leaves and will no longer be billing under the practice’s Tax ID #
Identifi Practice/Portal User Termination Form A provider or practice administrator leaves and will no longer need access to the WKCC Provider Portal and/or Identifi Practice