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Find a Provider / Pharmacy
Become a Provider

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Providers
Corporate
Find a Provider / Pharmacy
Become a Provider

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WellCare National

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Provider Enrollment
- Network Participation Request
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Add a Practitioner
Add a Facility
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Add a Facility Request Form

Skilled Nursing Facility - Ambetter and/or Medicare Only

Instructions for adding a facility to an existing contract.

Back to primary service type selections

Please populate the below.

Provider Name *

Error: Provider First Name is required.

NPI *

Error: NPI is required.

Medicare Number *

Error: Medicare Number is required.

License Number *

Error: License Number is required.

Line of Business (Select all that apply) required * Ambetter Medicare

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.

Are 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 Directory 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.

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 Information

Pay To Name *

Error: Pay To Name is required.

Street Address *

Error: Pay To Address is required.

City *

Error: Pay To City is required.

State *

Error: 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 Email 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 provide any additional information

Please download and fill out the forms below. *Attachments required for submission.

Disclosure of Ownership Form^*
W-9 Form^*
LOAP/Practitioner Roster Form (XLS)
Copy of Current Malpractice Certificare of Insurance^*
CVO Credentialing Form - Facility (PDF)^*
Provider Erollment Letter- advising of specific details of the enrollment request._* (On your company letterhead)
SNF Facility Licensure^*
CLIA Certificate (Required if Lab Services are performed at location)