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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.

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Ambetter or Medicare 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 (Wellcare by Allwell / Wellcare Complete)

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 *