Login / Register
Contact Us
Media Center
Help
WellCare National

English
Español

Enter Keyword

Members
Providers
Corporate
Find a Provider / Pharmacy
Become a Provider

Members
Providers
Corporate
Find a Provider / Pharmacy
Become a Provider

Login / Register
Contact Us
Media Center
Help
WellCare National

English
Español

Providers
Welcome to WellCare
Provider Enrollment
- Network Participation Request
Demographic Update
Add a Practitioner
Add a Facility
Informational Webinar
2026 Provider Summits
Provider Login
Contact Us
Non-Wellcare Providers
Medicaid
Medicare
- Claims
Tools
News and Education
- Provider Bulletins
- Provider Newsletters
Health Care Exchange
Ambetter
- Pre-Auth Check

Add a Practitioner to an Existing Contract or Location

To ensure your request can be processed, please make sure all required fields and data are fully completed and accurate. Additionally, all necessary documents must be attached and complete. Requests submitted with missing information will result in your request being discarded. Your provider representative will be informed of the missing information and will reach out to notify you. Once you are able to provide the necessary information, please resubmit your request using this online form.

Medical or Physical Health

Back to previous page

Please select Practice type required * Solo Practice Group Practice

Error: Practice Type is required.

Please populate the fields below:

Effective Date *

Error: This field is required.

Practitioner First Name *

Error: Practitioner First Name is required.

Practitioner Last Name *

Error: Practitioner Last Name is required.

Practitioner Type *

Error: Practitioner Type is required.

CAQH ID # *

Error: CAQH 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 (Please select all that apply) required * Medicaid Medicare 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.

Add PCP Status: required * Yes No

Error: PCP Status is required.

Accept New Membership Assignment: required * Yes No

Error: New Membership Assignment is required.

Primary Office/Service Address Information.

Practice Location Name *

Error: Practice Location 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.

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.

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: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 2

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 3

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 4

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

Error: This field is required.

Additional Location 5

Practice Location Name

Street Address

City

State

Zip Code

Error: Zip Code is required.

County

Phone Number

Error: Phone Number is required.

Fax Number

Error: Fax Number is required.

Are Lab Services performed at this location? Yes No

Error: Lab Services response is required.

CLIA Number

CLIA Expiration

Error: This field is required.

OPT out of Directory (Address will be listed in directory as long as provider is at this location 16 hours or more) Yes No

Error: This field is required.

Covering Location (Covering locations are not included in the directory) Yes No

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 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: 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 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 attach the documents listed below. * Attachments required for submission.

Disclosure of Ownership Form
W-9 Form
LOAP/Practitioner Roster Form (XLS) (Required for Group Practice with more than 15 practitioners)
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)

Disclosure of Ownership Form

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

W-9 Form *

Error: W-9 Form upload is required.

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

LOAP/Practitioner Roster Form

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

Copy of Current Malpractice Certificate of Insurance *

Error: Copy of Current Malpractice Certificate of Insurance upload is required.

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

CVO Credentialing Form - Practitioner (Completion of this form is required only in the absence of a CAQH profile.)

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

Provider Enrollment Letter advising of specific details of the enrollment request. (On your company letterhead) *

Error: Provider Enrollment Letter upload is required.

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

CLIA Certificate *

Error: CLIA Certificate upload is required.

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

Error: reCAPTCHA verification failed.

Error: Please add a Captcha.

Find a Provider
Member Login
Contact Us
Help

Accessibility
Privacy & Legal
Notice of Non-Discrimination

If you are unable to view PDFs, please download Adobe Reader.