Workers' Compensation Commission

HEALTHCARE PROVIDER INDIVIDUAL Please complete the fields below and select submit form for WCC approval. No access is available until your application process is completed. All fields marked with an * are required. Additional help with the application can be found HERE.
If you do not have a National Provider Identifier, go here first to apply. Email Your email address is used as your WFMS User ID. First Name Middle Last Name Suffix Street Address Additional Street Address e.g. room or suite number City State ZIP Work Phone Ext CMS National Provider Identifier Healthcare Provider Taxonomy Licensed State License Number