Medical Contract Request Form

Required fields are marked with an asterisk (*)

Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Legal Entity Name *

ATTN *

Provider Address *

City *

State *

ZIP Code *

Entity Tax ID *

Entity NPI *

Entity Medicaid Number * PLEASE NOTE: Enter "Medicaid ID Pending" if you are in the process of obtaining one from DHHS

W-9 *

Are you currently contracted with WellCare? *

Yes No Unsure

Estimate the number of practitioners you wish to enroll: *