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Network Participation Request Form: Pharmacist

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.

Board Certified Protocols

Please select identify all Board Certified Protocols that the provider has attestation. (Drop Down Selection. Select All That Apply) required * 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.

Attach 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.

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

Error: Form upload is required.

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

Attach 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.

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

Error: Form upload is required.

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

Attach 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.

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

Error: Form upload is required.

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

Attach 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: City is required.

Phone Number *

Error: Phone Number is required.

Fax Number *

Error: City is required.

Include in Provider Directory required * Yes No

Error: Provider Inclusion choice 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 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)

Please provide any additional information

Disclosure of Ownership Form *

Error: Disclosure of Ownership Form upload is required.

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.

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 - Facility *

Error: CVO Credentialing Form upload is required.

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.

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