Regence provider recredentialing application form 2025

1. Click ‘Get Form’ to open the regence provider recredentialing application form in the editor.
2. Begin by filling out the 'General Information' section. Enter your corporate name, Federal Tax Identification Number, and NPI Number. Indicate if your facility is owned by a hospital system and provide the effective date.
3. Proceed to the 'Organizational Provider Type' section. Select the appropriate type of facility from options such as Ambulatory Surgery Center or Hospice, ensuring you check all that apply.
4. In the 'Demographic/Location Information' section, complete all address fields for your main office and any additional locations. Be sure to include contact names and phone numbers for each address.
5. Fill out the 'Payment/Billing Information' with details like reporting name and billing contact information. Attach a copy of your W-9 IRS form as required.
6. Complete sections on Licensure/Certification/Accreditation and Liability Insurance, providing necessary documentation as specified.
7. Answer questions in the 'Attestation Questionnaire' honestly, providing additional details on a separate sheet if necessary.
8. Finally, review all entries for accuracy before signing and dating the release of information authorization at the end of the form.

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