Regence Home Health is delegated starting 01/01/204 for states: ID, OR, UT, and WA. Submit this form if you are providing care for a member with a Regence health plan.

*This is for Home Health Providers only*

*For multiple sites please submit a request for each location.*

*For Post Acute Care providers- use the link provided:

https://app.smartsheet.com/b/form/047afcfc11f6462eaede85ded91e1743*

*If you need assistance completing this form, please reach out to providerdatamanagement@carelon.com*