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 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 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.

 

Portal Access