Express Enrollment Change Of Address

Welcome » July 1, 2025 6:57 PM

	Alerts
	Children’s Long-Term Support (CLTS) Program Providers and County Waiver Agencies: The CLTS Operations Team is available for your questions about submitting prior authorizations (PAs) or claims for CLTS services. Reach the CLTS Operations Team at 844-942-5870 or CLTSOperations@gainwelltechnologies.com.

Express Enrollment Change Request

»	Express Enrollment Change Request

Required fields are indicated with an asterisk (*).

This panel is for Partners, Providers, or Qualified Hospitals enrolled in Express Enrollment to make changes to their Express Enrollment certification. Information submitted on this panel will not be used to change a provider’s ForwardHealth enrollment information.
This form cannot be used to change an Express Enrollment Security Administrator. Changes to an Express Enrollment Security Administrator can be made in ACCESS for Partners and Providers. See Access Handbook Chapter 12 for more information.

PROVIDER/PARTNER

Partner/Provider Name*

Partner/Provider Name: Maximum characters required is (40).

Partner/Provider Number*

Partner/Provider Number: Maximum characters required is (10). Partner/Provider Number: Invalid Characters

ORGANIZATION

NameType Maximum characters required is (50).

FEIN/TIN Required input must be 9 characters in length. Invalid Characters

Express Enrollment Contact person for Partner/Provider/Qualified Hospital

Express Enrollment Contact Person
First Name	First Name: Maximum characters required is (15). Telephone Number Enter a valid value
Last Name	Last Name: Maximum characters required is (25). E-mail Address Enter a valid value
Title	Title: Maximum characters required is (40).

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Wisconsin Department of Health Services

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