Wellmark s 53260 2026

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2. Begin by entering your Submitter Name and Contact details. Ensure that the provider's NPI is valid as it is required for registration.
3. Fill in the Submitter Address fields accurately, including City, State, and Zip Code. This information is crucial for correspondence regarding your registration.
4. Indicate whether you already have a submitter ID by selecting 'Yes' or 'No'. If yes, provide the existing Submitter ID.
5. Complete the Provider Information section by entering Vendor Name, Provider Name, and Tax ID. If necessary, attach additional NPIs on a separate list.
6. Sign and date the form at the bottom. The signature must be from an authorized individual such as an office manager or administrator.
7. Once completed, fax or email the form to the provided contacts to initiate your registration process.

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