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Update an IRS Address

KanCare Provider Enrollment and Changes: Providers must use the Kansas Modular Medicaid System (KMMS) Provider Enrollment Wizard to update their information for any or all of the Medicaid fee-for-service (FFS) and managed-care organization (MCOs) health plans.

Medicare or Ambetter Update an IRS Address

Please use the form below to change your group's IRS address for Ambetter or Medicare members.

Change IRS Address for: * Ambetter (Health Insurance Marketplace) Medicare (Allwell / Wellcare)

Group/Facility Name *

Tax ID # *

Group NPI # *

IRS Address

Street Address *

Address Line 2

City *

State *

Zip / Postal Code

W9 Form

You can download a fillable W9 form from the IRS.

Please Attach a Completed W9

Comments

Update Requested By:

First Name *

Last Name *

Contact Email *

Contact Phone *