Workers' Compensation Commission

HEALTHCARE PROVIDER (ORGANIZATION)

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:*User ID, e.g. george@whitehouse.gov, must be unique to each subscriber
Authorized Official First Name:*First Name
Authorized Official Middle Name:Middle Initial or Middle Name
Authorized Official Last Name:*Last Name
Authorized Official Title/Position:*Position Title
Authorized Official Work Phone:*Work Phone
NPI:*National Plan and Provider Enumeration System assigned unique National Provider Identifier (NPI)
Organization Name:*Business Name (as insured or registered)
Street Address 1:*Address 1
Street Address 2:Address 2
City:*City
State:*State
ZIP:*ZIP Code, e.g. 12345-6789, last 4 digits optional
Taxonomy:*Provider Type