Wyoming.gov | Citizen | Business | Government | Visitor
Pharmacy Help Desk: 1-877-209-1264, Provider PA Help Desk: 1-877-207-1126
Update Pharmacy Provider Information
| To Update: | Complete: *If document is listed in red, then ORIGINAL documents must be returned. |
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Medicaid Pharmacy Provider Updates Form → Return by email, fax or mail (see Contact Information below) |
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Medicaid Pharmacy Updates – Pharmacist & Managing/Directing Employee Form → Return by fax or mail (see Contact Information below) |
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Wyoming Pharmacy Provider – Change in % Ownership or Board Members → Return by fax or mail (see Contact Information below) |
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Medicaid Pharmacy Provider Updates Form & Wyoming Vendor Management Form (VMF) & ORIGINAL Form W-9 → Return by mail (see Contact Information below) |
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Wyoming Vendor Management Form (VMF) (as well as ORIGINAL Form W-9 & ORIGINAL bank letter or ORIGINAL voided check) → Return by mail (see Contact Information below) |
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Medicaid Pharmacy Provider Updates Form, Pharmacy Provider Agreement (2 originals), Wyoming Vendor Management Form (VMF), and ORIGINAL Form W-9 → Return by mail (see Contact Information below) |
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Medicaid Pharmacy Provider Updates Form, Wyoming Vendor Management Form (VMF), and ORIGINAL Form W-9 → Return by mail (see Contact Information below) |
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***The information provided on the Vendor Management Form must match that provided on the Form W-9 and both forms must be ORIGINAL with ORIGINAL signatures. Please use the current Form W-9, found at http://www.irs.gov/pub/irs-pdf/fw9.pdf. These forms must be accompanied by an ORIGINAL VOIDED check or an ORIGINAL letter from your Financial Institution. ***The State of Wyoming will only accept 1) an ORIGINAL/unused VOIDED check; or 2) an ORIGINAL letter from your Financial Institution on Financial Institution letterhead, with a date not older than 1 year, signed by a bank representative, including the vendor/business name, routing #, account #, and account type (e.g. checking or savings). → PLEASE NOTE: The business name, address, and information must be consistent across the VMF, the W-9, and the check/bank letter. Please follow the “Wyoming State Auditor’s Office Instructions for Wyoming Vendor Management Form” found on the page before the VMF. |
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Change Healthcare EDI Access Form → Return by email, fax or mail (see Contact Information below) |
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| For any of the following reasons: | Contact Change Healthcare | ||||||||
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Phone: (877) 205-8083 |
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Contact Information:
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