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  • Premera Bcbs Form 004674 2014

Get Premera Bcbs Form 004674 2014-2025

State license (issued by a State Department of Health or Human Services Division) Current Drug Enforcement Administration (DEA) certificate (as applicable) Current Liability Insurance face sheet/certificate or a letter if coverage is self-insured or copy of surety bond ORGANIZATION/FACILITY 1: Name Facility Type: Complete Address.

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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.

  1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
  2. 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.
  3. Provide contact information, including the phone number, fax number, federal tax ID number, and NPI number, ensuring all details are accurate.
  4. Fill out the contact person's name, phone number, fax number, and contact address. Include the email address for communications.
  5. Indicate whether your facility provides language translation or interpreter services by selecting 'Yes' or 'No.'
  6. Complete the licensure section by entering the license number and confirming if the license is in good standing with the state.
  7. If applicable, provide the Medicare number and confirm whether your Medicare certification is in good standing.
  8. If your organization is registered with the DEA, enter the DEA number, otherwise select 'No.'
  9. 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.
  10. Accredited facilities must also provide their accreditation certificates and mark the relevant organizations from the list provided.
  11. For non-accredited facilities, attach the most recent State and/or Medicare survey and indicate any deficiencies along with corrective action plans.
  12. Answer the questions regarding your procedures for patient safety, any past criminal convictions, debarment status, and existing government sanctions.
  13. Sign and date the authorization and attestation section, providing your printed name and title.
  14. 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.

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No, Premera Blue Cross remains committed to serving Washington state. Recent updates confirm that they continue to provide health insurance options and services to individuals and families in the region. For those in Washington looking for additional resources, the Premera BCBS Form 004674 may assist in understanding your benefits.

The timely filing limit for Premera is typically 180 days from the date of service for most claims. Understanding this deadline is essential to ensure that your claims are processed without issues. If you have questions about your specific situation, utilizing the Premera BCBS Form 004674 can guide you through the process. For more information, the USLegalForms platform can provide valuable resources for navigating insurance filing matters.

Regence Blue Cross Blue Shield and Premera are not the same, although both are part of the BCBS association. Regence serves members primarily in Oregon, Washington, Idaho, and Utah, while Premera focuses on Washington and Alaska. Each provides its own unique range of plans and services tailored to their respective regions. Understanding these differences is crucial when dealing with forms like the Premera BCBS Form 004674.

Premera is owned by Premera Blue Cross, which is a not-for-profit health insurance company. This model allows Premera to focus on services that best meet the needs of its members while supporting the community at large. As a part of the larger healthcare landscape, Premera operates independently but collaborates within the BCBS framework. When looking at the Premera BCBS Form 004674, it’s important to recognize the company’s commitment to member service.

Premera and BCBS are connected, with Premera being a specific BCBS-affiliated provider. They collaborate to deliver a variety of health insurance plans and services. However, Premera customizes its offerings to meet the needs of its customers in its specific service areas. When filling out the Premera BCBS Form 004674, it can be helpful to remember that Premera tailors solutions for its members.

Premera is a part of the Blue Cross Blue Shield Association, but they are not identical. Premera offers unique plans and services, primarily to individuals and businesses in Washington and Alaska. While they carry the BCBS name, their offerings have distinct features. Users of the Premera BCBS Form 004674 should be aware of these differences when seeking coverage.

Regence and Blue Cross Blue Shield, or BCBS, are not the same entity, though they are connected. Regence operates as the Blue Cross Blue Shield plan in the Pacific Northwest, providing health insurance to members in that region. While they share resources and branding as part of the larger BCBS network, they offer their services independently. For those using Premera BCBS Form 004674, understanding these distinctions can be important for navigating insurance options.

To fill out a medical authorization form, start with your personal details, including your full name and date of birth. Identify the healthcare provider or entity that will receive your medical information, specifying what data you allow them to share. Make sure to state the purpose of the authorization and any expiration date if applicable. Sign and date the form once complete. Utilizing the Premera BCBS Form 004674 can guide you through this process efficiently.

Deciding whether to accept or decline HIPAA authorization depends on your comfort level with sharing your health information. Accepting authorization allows healthcare providers to share your information for treatment or payment, which can be beneficial for your care. However, declining may offer you more privacy, yet it might limit access to services. Carefully consider your needs and consult with your healthcare provider if unsure about the implications. The Premera BCBS Form 004674 can assist in understanding your rights.

Yes, Premera Blue Cross often requires prior authorization for certain medical services and procedures to ensure they are medically necessary. This process helps manage costs while ensuring that members receive appropriate care. When planning your treatment, check with your provider or Premera's customer service to understand which services need prior authorization. The Premera BCBS Form 004674 may include important details regarding these authorization requirements.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232