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Regence enrollment change form

Regence application form 2026

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4.8 out of 5

277 votes

The document is an application form for enrollment, change, or termination of health insurance coverage with Regence BlueShield. It includes sections for personal information, eligibility details, plan selection, and member enrollment. The form requires completion in black ink and emphasizes the importance of legibility and completeness to avoid delays in coverage. Additionally, it outlines the process for COBRA or non-COBRA continuation enrollment and provides a nondiscrimination notice regarding language assistance services.

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Click ‘Get Form’ to open the regence application form in the editor.
Begin by filling in your Group Number, Subgroup, and Class. These fields are essential for identifying your group coverage.
Enter your personal details including Employee Last Name, First Name, Middle Initial, and Date of Hire. Ensure all dates are formatted as mm/dd/yyyy.
Complete the Employee Mailing Address and Physical Address sections. If both addresses are the same, simply check the box provided.
Indicate your Marital Status by selecting the appropriate option. If applicable, provide additional information regarding any changes or special enrollments.
In the Plan Selection section, choose your desired medical and dental plans based on options provided by your Group Administrator.
List all members you wish to enroll or change coverage for in the Enrolling Members section. Be sure to include their relationship to you and relevant details.
Finally, review all entries for accuracy before signing and dating the application at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (277 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Why does insurance credentialing take so long?

Thorough Verification Requirements The exhaustive nature of the verification process is one of the main reasons why does credentialing take so long. Each aspect needs to be thoroughly validated and checked for a providers qualifications.

Is Blue Cross Blue Shield the same as Regence?

Is Regence the same as Blue Cross Blue Shield? Regence is not the same as Blue Cross Blue Shield.

Is Regence HMO or PPO?

Regence offers mostly PPO Medicare Advantage plans, but also offers some HMO plans.

What states does Regence cover?

As the largest health plan in the Northwest/Intermountain Region, we serve more than 2.4 million members in Idaho, Oregon, Utah and Washington through their workplace or personal health insurance coverage.

How long does it take to get credentialed with Blue Cross?

The credentialing process typically takes 45 days from the time the credentialing department receives your completed CAQH application.

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What is the typical timeline for insurance credentialing?

Typical Credentialing Timelines Initial credentialing typically lasts between three to six months, involving preparation (two to four weeks), application review (60120 days), and final enrollment (two to four weeks). Recredentialing, which occurs every two to three years, is often shorter.

How long does credentialing take?

The general timeframe for healthcare providers to complete credentialing is between 90 to 120 days. However, this is an average estimate. Some payors may complete the process quicker, while others might take longer, especially for certain specialties.

How long does it take to get credentialed with Regence?

Completion of the credentialing process takes 30-60 days. We will notify you if additional information is needed. View your credentialing status in Payer Spaces on Availity Essentials.