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||An existing provider leaves the practice and is no longer billing through the practice’s Tax ID #|
|New Practice / Location|
Please also fill out the New Provider form for all of the providers in the new practice or location.
|Practice / Location Exit Form||A provider leaves and will no longer be billing 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 Practice|
|Core Requirement Exemption Form||You need to request a core requirement exemption for one of your providers.|