Workers' Compensation Commission

HEALTHCARE PROVIDER DELEGATE 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.
Email Your email address is used as your WFMS User ID. Password 8-25 chars with at least 1 number. Show password Confirm Password First Name Middle Last Name Suffix Street Address Additional Street Address e.g. room or suite number City State ZIP Work Phone Ext Mobile Phone Mobile or 2nd phone number