Practitioner Notification Form

The Practitioner Notification Form is for our participating providers that are currently in our network. If your facility is interested in joining our network, please complete the Participating Provider Request Form.

This form should be used when a practitioner is joining or leaving your organization, adding or terminating a practice location, or has other demographic changes such as name, licensure, in directory or accepting new patients indicators.

We recommend using one of the following browsers: Chrome, Edge, or Firefox to complete the Practitioner Notification Forms.

For changes specific to facilities such as notifying us of a facility closure, updating a facility address, phone, or fax number, please use the Facility Notification Form. This form is only intended for practitioner notifications.

Need help filling out this form?

Are you adding a practitioner?:

Yes

Select this option if a practitioner is joining your organization.

Are you updating a practitioner?:

Yes

Select this option if an existing practitioner with your organization is adding or terming a practice location, when a practitioner changes their name, specialty, degree/credentials, licensure, or status at a practice location such as no longer accepting new patients.

Full termination of a practitioner?:

Yes

Select this option if an existing practitioner is completely terminating from your organization for all practice locations.

Add Practitioner

Start Date*

Tax ID#*

Practitioner Last Name*

Practitioner First Name*

Practitioner Middle Initial

Credential/Degree*

Date of Birth*

Gender*

Male

Female

CAQH Provider ID Number

Spoken Languages*

Has Practitioner Completed Cultural Competency Training?*

Yes

Practitioner Email*

License

In-Training/Non-Licensed*

Yes

Please list all active licenses for the provider

Practitioner NPI#	License Type(s) Please list in highest to lowest order)	License #	License State	License Expiration Date

Is this provider Medicare certified?*

Yes

Medicare Number*

Medicare State*

Medicare Effective Date*

Participating*

Yes

Accepting Assignment*

Yes

Is this provider Medicaid certified?*

Yes

Medicaid Number*

Medicaid State*

Medicaid Effective Date*

Is the rendering NPI Medicaid Certified as a a billable provider for Wisconsin Medicaid (BadgerCare)? A rendering NPI isn't necessarily a billable NPI for Medicaid.

Yes

Facilities

Please list all facilities where practitioner will be practicing. Select one as primary location.

Add New Facility (with Specialty)

Primary
Location

Facility Name*

Address*

City*

State*

Zip*

County*

Phone*

Clinical or Referral/
Authorization Fax*

Practitioner
Type*

Practitioner Status*

Specialty*

Taxonomy Code*

Primary Care

Specialist

Should provider be listed in directory at this location?*

Yes

Is provider an eligible Primary Care Provider (PCP) at this location?*

Yes

Accepting New Patients at this location?*

Yes

Does this practitioner offer Telehealth services?*

Yes

Hospital Affiliations

List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.

Hospital Name	Address	City	State	Zip

Practitioner's Billing Information

Billing Name for Services Rendered by this practitioner*

Address*

City*

State*

Zip*

Billing NPI#*

Taxonomy Code*

Practitioner Employed by Organization*

Yes

Comments

Credentialing Recipient*

Address*

City*

State*

Zip*

Phone*

Fax*

Email Address*

Updating Practitioner

Clinic Name*

Tax ID*

Billing Name*

Billing NPI#*

Practitioner Name*

Practitioner NPI*

Reason for Change*

Effective Date*

Old Information*

CAQH Provider ID Number

New Information*

Update Practitioner Culture

Change Request*

Adding a practice location to an existing practitioner?*

Yes

Facilities

Please list new facilities where practitioner will be practicing.

Facility (with Specialty)

Primary
Location

Facility Name*

Address*

City*

State*

Zip*

County*

Phone*

Clinical or Referral/
Authorization Fax*

Practitioner
Type*

Practitioner Status*

Specialty*

Taxonomy Code*

Primary Care

Specialist

Should provider be listed in directory at this location?*

Yes

Is provider an eligible Primary Care Provider (PCP) at this location?*

Yes

Accepting New Patients at this location?*

Yes

Does this practitioner offer Telehealth services?*

Yes

Terming a practice location for an existing practitioner?*

Yes

Please list all facilities that the practitioner is terming from

Facility Name	Address	City	State	Zip	Termination Date	Why is Practitioner Leaving

Updating Practitioner Information (Name Change, Degree Change)?*

Yes

Practitioner Last Name

Practitioner First Name

Practitioner Middle Initial

Credential/Degree

Change in Licensure?*

Yes

License

In-Training/Non-Licensed:*

Yes

Please list all active licenses for the provider

Practitioner NPI#	License Type(s) Please list in highest to lowest order)	License #	License State	License Expiration Date

Is this provider Medicare certified?*

Yes

Medicare Number*

Medicare State*

Medicare Effective Date*

Participating*

Yes

Accepting Assignment*

Yes

Is this provider Medicaid certified?*

Yes

Medicaid Number*

Medicaid State*

Medicaid Effective Date*

Is the rendering NPI able to be a billable NPI for BadgerCare members? A rendering NPI isn't necessarily a billable NPI for Medicaid.

Yes

Update Hospital Affiliations?

Yes

Hospital Affiliations

List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.

Hospital Name	Address	City	State	Zip

Terminating Practitioner

Practitioner Last Name*

Practitioner First Name*

Practitioner Middle Initial*

Practitioner NPI*

CAQH Provider ID Number

Termination Date*

What location(s) is practitioner terminating from?*

Practicing Site Name/City

Tax ID#*

Billing Name

Billing NPI#*

If practitioner is a Primary Care Physician, who will be taking members currently assigned to practitioner

If practitioner is a Specialist, who will be taking referrals that were assigned to practitioner

How will members be notified of this change*

If this was the only practitioner at the site, will practitioner be replaced:

Yes

If so, when:

Where will the terminating practitioner be going (required by Wis. Law)*

Enter New Practice*

Practitioner Site Name/City*

Phone

Why is Practitioner Leaving*

Enter Other Reason:

Completed By: *

Email: *

Phone: *

*Indicates a required field

Practitioner Notification Form

Add Practitioner

License

Facilities

Hospital Affiliations

List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.

Practitioner's Billing Information

Updating Practitioner

Facilities

License

Hospital Affiliations

List all hospitals where the practitioner has privileges to examine, treat, and manage patients as outpatient or inpatient within the hospital.

Terminating Practitioner

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