Get Regence Provider Recredentialing Application Form

Completing the Regence Provider Recredentialing Application Form online is a crucial step for healthcare organizations seeking to maintain their provider status. This guide will walk you through each section of the form to ensure that you provide accurate and complete information.

Follow the steps to successfully complete the application.

1. Click the ‘Get Form’ button to obtain the Regence Provider Recredentialing Application Form and open it in the appropriate editor.
2. Start by filling in the general information section. Include the corporate name as listed on your W9, Federal Tax Identification Number, and the NPI Number. Indicate if the facility is wholly or partially owned by a hospital system and provide the effective date.
3. In the organizational provider type section, check the category that best describes your facility, such as an ambulatory surgery center or a hospice. Fill out additional information as necessary based on your selected type.
4. Complete the demographic/location information by providing the main office address, mailing address, and contact information. Make sure to check the appropriate address types.
5. Fill out the payment/billing information. Include the reporting name, corporate name, tax ID number, and billing contact details. Attach a copy of the W-9 IRS form as required.
6. Provide details regarding licensure, certification, and accreditation. Include your state license number, expiration date, and indicate participation in Medicare or Medicaid programs. Attach copies of all relevant licenses and certifications.
7. In the liability insurance section, provide the name of the insurance carrier, policy number, and coverage details. Attach your current professional and general liability insurance documentation.
8. Fill in ownership/management information with details for the president, CFO, and medical director, including their names, titles, and contact numbers.
9. Complete the attestation questionnaire honestly, providing details on a separate sheet if necessary. Responses to legal or compliance issues are critical for the review process.
10. In the staffing section, state whether your facility validates the credentials for licensed practitioners. Provide details of your credentialing process.
11. Certify the exclusion certification information outlining your commitment to verifying the eligibility of all new hires against federal exclusion lists.
12. Finally, complete the release of information and authorization section, providing an authorized signature, date, printed name, and title before submitting the completed form.
13. Once all sections are filled out, review the form for accuracy. You have the option to save your changes, download, print, or share the completed form as needed.

Complete your Regence Provider Recredentialing Application Form online today for a smooth credentialing process.