Loading
Get Wi Anthem Provider Letter Of Intent
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the WI Anthem Provider Letter of Intent online
The WI Anthem Provider Letter of Intent is an essential document for individuals and organizations seeking to become in-network providers for Anthem BlueCross and BlueShield in Wisconsin. This guide offers clear, step-by-step instructions to assist users in accurately completing the form online.
Follow the steps to complete the form online effectively.
- Click ‘Get Form’ button to access the Letter of Intent form and open it in your online editor.
- Begin by filling in the practice name, which refers to the group, corporation, clinic, or agency you represent.
- Enter the practitioner's full name, including their first name, middle initial, last name, and title (e.g. John A. Smith, MD).
- Input your CAQH number, which is essential for provider credentialing.
- Provide your date of birth to assist in identifying and verifying your credentials.
- Indicate your gender by selecting the appropriate box (F or M) as required.
- Fill in your tax identification number for financial identification purposes.
- Input your state license number to confirm your professional standing.
- Specify your specialty. If applicable, especially for Behavioral Health providers, clarify your exact role (e.g., Counselor, Psychologist, Social Worker).
- If you are a Wisconsin Autism Qualified Provider, attach the relevant certification form found at the Anthem website.
- List the languages you speak to cater to a diverse client base.
- Indicate the age range of clients you work with to clarify your target demographic.
- Enter your individual National Provider Identifier (NPI) number here.
- Include your practice contact information, including the name and email address.
- Provide both your primary office address and billing office address, including street, city, state, zip code, and phone/fax numbers.
- Read the information regarding credentialing in Part II, ensuring you understand the processes that follow your submission.
- Finally, ensure you sign and date the form to authenticate your application.
- After filling out all sections, review the information for accuracy and completeness, then save your changes, download, print, or share the completed form as required.
Complete your WI Anthem Provider Letter of Intent online today and ensure your application is submitted correctly.
To terminate your provider contract with Anthem, start by reviewing the terms outlined in your contract. Contact Anthem’s provider services to express your intention clearly. Be prepared to provide any necessary documentation, such as a WI Anthem Provider Letter of Intent, to formalize the termination process and make it smooth.