HVS New Provider

Use this form to add a provider to an existing WKCC High Value Specialist practice. If your practice is not already a WKCC High Value Specialist participant, please fill out the practice inquiry form.

Provider NPI *

National Provider Identifier

Provider Name *

First

Last

Work Cell # *

To be used only for STAT, emergent, and professional consultations with WKCC providers

Work Email Address *

Gender *

Degree *

Primary Specialty *

Secondary Specialty

Practice Name

Primary Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Location Office Phone # *

Additional Practicing Addresses?

If yes we will reach out to acquire additional locations.

Start Date *

Submitter Name *

First

Last

Submitter Email *

I agree to the terms and conditions below. *

I agree

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases WakeMed and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof. By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form. Plus, by completing this form, I am agreeing to receive relevant health information from WakeMed. I understand I can opt-out from these communications at any time.

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