Click on the download link to download the form you want.
|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|
|Dental Credentialing/Recredentialing Application||Download|
|Network Group Provider Information 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.