Follow the steps to complete the credentialing application accurately.

1. Click ‘Get Form’ button to obtain the form and access it in the online editor.
2. Begin by entering your personal details in the appropriate fields, including your first name, last name, and email address. Ensure that all information is accurate, as this will be used for confirmations and documentation.
3. Complete the application by filling out all required sections thoroughly. Keep in mind that incomplete applications may lead to delays in processing your credentialing.
4. Attach a copy of your CP 575 or 147C letter from the Internal Revenue Service. This is necessary for tax identification verification.
5. After filling in the application, ensure that you sign the required pages (10, 11, and 12) electronically.
6. Once you have completed the application and signed the necessary pages, return the entire application along with the supporting documentation. You can do this via email or fax as instructed in the application guidelines.
7. Retain a copy of the completed application and all submitted documentation for your records.
8. Finally, be prepared to monitor the status of your application. You may inquire about your application status through the Credentialing department if needed.

Start filling out your Regence BlueCross BlueShield of Utah Practitioner Credentialing Application online today!