New Provider Billing Registration Form

1-866-992-6600

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Frequently Used Forms

Welcome to Community Care. We value you as a provider and want to let you know we have multiple methods of submitting claims. We would like to work with you on what method best works for your organization to ensure timely and accurate payment. Please complete the following form with the requested information and Community Care will contact your facility.

This form should only be completed by providers who are contracted with Community Care. If you have questions about whether or not you are contracted please call 866-937-2783 and select option 2 prior to submitting this form.

Facility/Location Name:

Contact Name:

Contact Address:

Contact Address Line 2:

City

State

Zip Code:

Contact Phone Number:

Contact Email Address:

Tax ID Number:

Types of Services Provided:

Specific Questions or Concerns:

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PLEASE NOTE: Upon pressing the submit button, you should see a message stating that we have received your information. If you do not, please scroll up, complete any of the required fields noted in red, then submit the form again.

Corporate Headquarters: 205 Bishops Way, Brookfield, WI 53005
Phone: (414) 231-4000 | Toll Free: 1-866-992-6600 | TTY: Call the Wisconsin Relay System at 711
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