LifeWorks Other Providers Form
The fields marked with an * below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at Central.DB@Ceridian.com or call our Provider Line at 800 290-4311, extension 5862. Leave your name and phone number and someone will return your call.
* New Provider Information    Updated Provider Information
Provider Name *
Phone *	()-
Main Contact *
Address *
City *
State *	AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WI WV WY
Zip *
Email Address *
Provider Type *
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