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Get Wi Care Wisconsin Provider Update Form
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How to fill out the WI Care Wisconsin Provider Update Form online
Completing the WI Care Wisconsin Provider Update Form online is an important step in ensuring that your organizational information remains current and accurate. This guide will provide you with clear, step-by-step instructions to help you fill out the form efficiently.
Follow the steps to effectively fill out your Provider Update Form.
- Click ‘Get Form’ button to access the form and open it in your online editor.
- Fill in the organizational information section. Include the contracted entity name, the person submitting the form along with their title, email address, taxpayer ID, phone number, and fax number.
- Indicate the reason for the update by selecting the relevant sections. Options include contact information change, practitioner change, tax ID change, service location change, or legal name change.
- For section 1, updated organizational information, provide the effective date for the changes and fill in only the applicable fields that require modification. Remember to attach a current W9 for any tax ID changes.
- In section 2, updated practitioner information, complete the fields for the practitioner's last name, first name, middle name, NPI, primary and additional specialties. Be sure to indicate if they are accepting new patients or if they are a primary care provider.
- For section 3, service location change, update all required fields for the old and new locations, including details such as address, taxpayer ID, phone number, and whether the location is handicap accessible.
- Review all provided information carefully to ensure accuracy and completeness before final submission.
- Once you have verified that all details are correct, save your changes, and download or print the completed form as needed. You can also choose to share the form directly.
Complete your documents online today to ensure your information is up to date.
To change ownership of your Medicaid provider in Wisconsin, you must submit a request to your local Medicaid agency. This process may require specific documentation to validate your new ownership status. For assistance in ensuring you submit the right forms, consider using the WI Care Wisconsin Provider Update Form, which simplifies the update process.
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