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Network Participation Request Form: Medical or Physical Health

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.

Medical or Physical Health

Back to primary service type selections

Please select Provider type required * Solo Practice Group Practice

Error: Provider Type is required.

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: Provider 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 (Please select all that apply) required * Medicaid Medicare Ambetter

Error: Line of Business is required.

CLIA Number *

Error: CLIA Number 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.

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.

CLIA Number *

Error: CLIA Number is required.

CLIA Expiration *

Error: CLIA Expirationis required.

Include in Provider Directory required * Yes No

Error: Provider Inclusion choice is required.

Additional Locations - Please list alternate and/or covering-only locations below.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Pay To Address

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 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 provide any additional information

Please attach the documents listed below. * Attachments 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 - Facilit (PDF)
Provider Erollment Letter advising of specific details of the enrollment request. (On your company letterhead)