Get Ut Regence Form 8125ut 2022-2025

The UT Regence Form 8125UT is a critical document for organizations seeking credentialing or recredentialing with Regence BlueCross BlueShield of Utah. This guide provides step-by-step instructions to help you complete the form accurately and effectively online.

Follow the steps to complete the UT Regence Form 8125UT online

1. Click the ‘Get Form’ button to access the form and open it in your editing platform.
2. Begin with the general information section. Fill in the corporate name as assigned on CP 575 or 147C, along with the Federal Tax Identification Number and NPI number.
3. Next, indicate the effective date in the format mm/dd/yyyy. Then, answer whether the facility is owned wholly or partially by a hospital system by selecting 'Yes' or 'No'.
4. Proceed to the organizational provider type section. Select the appropriate type of facility by checking the relevant box, such as 'Ambulatory Surgery Center' or 'Substance Use Disorder,' and provide necessary details if applicable.
5. Move to the demographic/location information section. Provide the facility’s main office address, checking whether it's a primary office or mailing address, and complete additional contact details such as phone number and email.
6. Continue to the payment/billing information section. Fill in the reporting name, corporate name, tax ID number, and billing contact information.
7. In the licensure/certification/accreditation section, enter the state license number, expiration date, and Medicare/Medicaid provider status, including relevant numbers.
8. Provide details regarding liability insurance, including the insurance carrier, policy number, dates of coverage, and coverage amounts.
9. Complete the ownership/management information by providing details for the president/CEO, CFO, and medical director, along with any other managing employees.
10. Answer the attestation questionnaire, marking 'Yes' or 'No' as appropriate. If any questions are marked 'Yes,' prepare to provide details on a separate sheet.
11. Fill out the staffing section, indicating whether credentialing processes are validated and how they are conducted.
12. Complete the exclusion certification by checking the box and signing the authorization section, including your printed name, title, and date.
13. Finally, review the entire form for accuracy. Once satisfied, you can save changes, download, print, or share the completed form as needed.

Start filling out the UT Regence Form 8125UT online today for efficient credentialing!