WKCC New Provider Form

In order to ensure that your providers are added as qualified participants of the ACO and get access to all the services and tools provided by WKCC, please fill out this form. If you do not have ALL REQUIRED information, please wait until all information needed can be provided. This will help alleviate any payer data confusion. Please ensure ALL payer data is entered correctly, Incorrect information will be rejected resulting in longer payer billing processing time.

Provider NPI*

Required for payer data.

Provider First Name*

Provider Middle Initial

Provider Last Name*

Provider Email Address*

Gender*

Select

Degree*

Provider Type*

Select

Provider's Date of Birth*

MM/DD/YYYY

CAQH ID*

Council for Affordable Quality Healthcare Identification. Required for payer data. WAKEMED providers MUST provide their CAQH ID. Incomplete CAQH ID will be rejected.

Do you have Provider's PTAN ?

If PTAN number is pending assignment from Medicare, Please update Population Health Specialist, when assigned. Late submission or notice will backlog provider billing processing. If provider doesn't see Medicare patients ex: Pediatricians, please enter YES and then NOT enrolled in Medicare.

Select

Provider PTAN*

Select or enter value

Primary Specialty*

Please enter a primary specialty as this is required for Cigna Mid-level credentialing.

Select or enter value

Secondary Specialty

Practice Office Number*

TIN

TIN Name

Group NPI*

Practice Name*

CARY MEDICAL CLINIC

Primary Location Address Line 1*

Primary Location Address Line 2

Primary Location City*

Primary Location State*

Primary Location ZIP*

County*

Select

Does the provider work at multiple locations?*

This is for TIN/practices that has providers working at multiple locations. If so, please enter secondary address below. If not, skip secondary location.

Select

Secondary Location Group NPI

Secondary Practice Name

Secondary Location Address Line 1

Secondary Location Line 2

Secondary Location City

Secondary Location State

Select or enter value

Secondary Location Zip Code

Secondary Practice Office Number

Phone

Billing/Remittance Name*

Billing/Remittance Address Line 1*

This is REQUIRED in order to be paid by payers.

Billing/Remittance Address Line 2

Billing/Remittance Address City*

Billing/Remittance Address State*

Billing/Remittance Address Zip*

Billing Phone Number*

Start Date*

Submitter First Name*

Submitter Last Name*

Submitter Email Address*

I agree to Terms and Conditions*

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases WKCC and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof. By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form. Plus, by completing this form, I am agreeing to receive relevant health information from WKCC. I understand I can opt-out from these communications at any time.

Send me a copy of my responses

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