Application request

Provider application request

Completion of this application request form indicates your interest only. You will be contacted by a Provider Relations Representative regarding next steps.

Note: Completion of this form is not part of the credentialing application for the network participation.

Fields marked with an * must be completed.

First Name *

Please enter the provider's first name

Last Name *

Please enter the provider's last name

Primary Specialty *

Please choose the option that best fits your primary specialty based on the menu options

Practice/Group Name

Primary Practice Address *

Please enter the complete mailing address (Ex: 123 Main St., City, State)

City

State

Zip Code *

Please enter your 5 or 9 digit postal code

County *

Please enter the name of your county

Office Phone *

Please enter your 10-digit office phone number (XXX-XXX-XXXX)

Fax

Please enter your 10-digit fax number (XXX-XXX-XXXX)

Email Address *

Please enter your email in a valid format (Ex: jdoe@emailus.com)

Contact Person *

Contact must be able to provide additional info for credentialing/contracting if needed

NPI

Please enter your 10-digit National Provider Identifier (NPI) number or your National Plan and Provider Enumeration System (NPPES) number if you do not yet have an NPI number

CAQH ID

Please enter your Council for Affordable Quality Healthcare (CAQH) 8-digit ID number

Select Market *

Please enter your market from the drop down selection

Submit

CAQH

Wellpoint accepts CAQH applications.

More about CAQH

Application request

Provider application request

CAQH

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