Providers

Forms

Click on the download link to download the form you want.

Description File
Provider Adjustment Appeal Form Download
Prior Authorization Form Download
Provider Credentialing Form - WellHealth Quality Care Download
Provider Re-Credentialing Form - WellHealth Quality Care Download
Provider Complaint Form - WellHealth Quality Care Download
EFT Enrollment Form Download
Letter of Interest Download
Provider Change in Name or Tax ID Form Download
W-9 Form Download
Dental Credentialing/Recredentialing Application Download
Network Group Provider Information Form Download
Group ACT Form Download

When you have completed your form in its entirety, please email to the appropriate email listed directly on the form itself. Should you need any assistance please contact us.

Attention Providers: Please note a change in department phone numbers. Click here for more information

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