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||
|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|