PH: (800) 801-9772 | (316) 683-4111
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Consent and Release

To initiate the recredentialing process as a provider in ProviDRs Care Network, please complete the below Consent and Release form.  Once submitted, you will be contacted to complete the recredentialing process.

Fax:     (316) 683-6255
Mail:   1102 S Hillside
Wichita, KS 67211

Should you have any questions, please contact Credentialing at 1 (800) 801-9772 or email us at  If you would like to print a copy of the Consent and Release form, please select the NEED HELP in the upper right hand corner of the box below and select Download PDF.

Please complete the below form with the Provider’s information.