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Get Premera Bcbs Form 004674 2014-2026
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How to fill out the Premera BCBS Form 004674 online
Filling out the Premera BCBS Form 004674 online can streamline the credentialing or recredentialing process for your organization or facility. This guide will provide you with clear, step-by-step instructions to ensure that you accurately complete the form without unnecessary complications.
Follow the steps to successfully fill out the form online.
- Click ‘Get Form’ button to access the form and open it in your preferred editor.
- Begin by entering the organization or facility name in the designated field, followed by the facility type and complete address, including city, state, and zip code.
- Provide contact information, including the phone number, fax number, federal tax ID number, and NPI number, ensuring all details are accurate.
- Fill out the contact person's name, phone number, fax number, and contact address. Include the email address for communications.
- Indicate whether your facility provides language translation or interpreter services by selecting 'Yes' or 'No.'
- Complete the licensure section by entering the license number and confirming if the license is in good standing with the state.
- If applicable, provide the Medicare number and confirm whether your Medicare certification is in good standing.
- If your organization is registered with the DEA, enter the DEA number, otherwise select 'No.'
- Upload or attach a current copy of your liability insurance face sheet, indicating the carrier's name, organization covered, dates, and amount of coverage. Include a letter if self-insured.
- Accredited facilities must also provide their accreditation certificates and mark the relevant organizations from the list provided.
- For non-accredited facilities, attach the most recent State and/or Medicare survey and indicate any deficiencies along with corrective action plans.
- Answer the questions regarding your procedures for patient safety, any past criminal convictions, debarment status, and existing government sanctions.
- Sign and date the authorization and attestation section, providing your printed name and title.
- After completing all sections, review the document for accuracy. You can then save changes, download, print, or share the form as needed.
Complete your Premera BCBS Form 004674 online today for a smooth credentialing experience.
Regence operates as a licensee of the Blue Cross Blue Shield Association, similar to Premera, but is a separate company. Each entity operates under its own policies and coverage options. For those looking for clarity on their health coverage, reviewing the Premera BCBS Form 004674 can be beneficial as it outlines essential information.