Provider Change Forms

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

USE THIS FORM	IF…
New Provider Form	A new provider joins your practice
Provider Exit Form	An existing provider leaves the practice and is no longer billing through the practice’s Tax ID #
New Practice / Location Form	A new practice joins under an existing Tax Id # of a WKCC participant If you are an existing WKCC participant adding a new location to an existing Tax ID # 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 Form	A practice or location will no longer be participating with WKCC or under the practice’s Tax ID #
Portal User Termination Form	A provider or practice administrator leaves and will no longer need access to the WKCC SharePoint Portal and/or Arcadia
Core Requirement Exemption Form	You need to request a core requirement exemption for one of your providers.