Tornados in Kentucky – Relief Response. Learn More.

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Network Participation Request Form

PLEASE NOTE: This is not a guarantee of Contract. The information you provide is used by Wellcare of KY to evaluate the offering of a Contract and is not representative of an application or a Legal Agreement. Requests are processed in the order they are received. Reviews will be performed within one (1) business week. A member of our team will contact you to relay if a decision is made to move forward with the contracting process within your region.

If you are not contracted with Wellcare of KY, complete the Network Participation Request Form below.

Pharmacist - Ambetter Only

Back to primary service type selections

Please select Provider type required * Solo Practice Group Practice

Error: Provider Type is required.

Administration of Medications, Biologics, and Vaccines

Administration of Medications, Biologics, and Vaccines required * Yes (if Yes attached the CE Certification Certificate) No

Error: Administration of Medications, Biologics, and Vaccines is required.

Upload CE Certification Certificate *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Board Certified Protocols

Please identify all Board Certified Protocols that the provider has attestation. (Select All That Apply) Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol v5 Acute Influenza Infection: Antiviral Therapy Protocol Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy Colorectal Cancer (Crc) Screening Protocol Acute, Uncomplicated Urinary Tract Infection Treatment Protocol Tuberculin Skin Testing Two-Step Protocol: For initial testing in adults who will be undergoing annual testing Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy

Error: Board Certified Protocol is required.

Please attach all attestations for each Board Certified Protocol selected.

Upload attestation for: Acute Group A Streptococcal (GAS) Pharyngitis Infection Protocol *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Acute Influenza Infection: Antiviral Therapy Protocol *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Alcohol Use Disorder Protocol utilizing Naltrexone-based Therapy *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Colorectal Cancer (Crc) Screening Protocol *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Acute, Uncomplicated Urinary Tract Infection Treatment Protocol *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Tuberculin Skin Testing Two-Step Protocol *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Upload attestation for: Opioid Use Disorder Protocol Utilizing Naltrexone-Based Therapy *

Error: Form upload is required.

Items in the trash will be permanently removed after 30 days.

Please populate the below.

Provider First Name *

Error: Provider First Name is required.

Provider Last Name *

Error: Provider Last Name is required.

Practitioner Type *

Error: Practitioner Type is required.

CAHD ID # *

Error: CAHD ID # is required.

NPI *

Error: NPI is required.

Medicaid Number *

Error: Medicaid Number is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: License Number is required.

Line of Business required * Ambetter

Error: Line of Business is required.

Group Name *

Error: Group Name is required.

Tax Identification Number *

Error: Tax Identification Number is required.

Group NPI *

Error: Group NPI is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expiration is required.

Include in Provider Directory required * Yes No

Error: Provider Inclusion choice is required.

Do you offer Telemedicine Services? required * Yes No

Error: Telemedicine Services information is required.

Do you participate with KHIE (Kentucky Health Information Exchange)? required * Yes No

Error: KHIE information is required.

Additional Locations - Please list alternate and/or covering-only locations below. One practitioner can have up to 5 covering locations.

Number of addtional locations

Additional Location 1

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 2

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 3

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 4

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Additional Location 5

Practice Location Name

Street Address

City

State

Zip Code

Error: This field is required.

County

Phone Number

Error: This field is required.

Fax Number

Error: This field is required.

Is Lab Services performed at this location? required * Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

Correspondence Address

Contract Entity Name *

Error: Contract Entity Name is required.

Street Address *

Error: Street Address is required.

City *

Error: City is required.

State *

Error: State is required.

Zip Code *

Error: Zip Code is required.

County *

Error: County is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: Fax Number is required.

Pay To Address

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: Pay To State is required.

Zip Code *

Error: Pay To Zip Code is required.

Your Contact Information

Primary Contact Name *

Error: Primary Contact Name is required.

Phone Number *

Error: Primary Contact Phone Number is required.

Email *

Error: Primary Contact Phone Number is required.

Credentialing Contact Name *

Error: Credentialing Contact Name is required.

Phone Number *

Error: Credentialing Contact Phone Number is required.

Email *

Error: Credentialing Contact Email is required.

Please attach the documents listed below. * Attachments that may be required for submission.

Disclosure of Ownership Form (PDF)
W-9 Form (PDF)
LOAP/Practitioner Roster Form (XLS)
Copy of Current Malpractice Certificare of Insurance
CVO Credentialing Form - Practitioner (PDF)
Provider Erollment Letter - advising of specific details of the enrollment request. (On your company letterhead)
CE Certificate - Administration of Medications, Biologics and Vaccines
Board Protocols Attestation
CLIA Certificate