Agency Information Form-Regence

Agency Information Form-Regence

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*

Agency Information

Provider NPI Number*

Provider Tax I.D #*

Is the provider Medicare Certified?*

Select

Medicare #

*Only enter your 6 digit Medicare number*

Legal Name (Provider Name)*

Parent Company

Site Location Information

Physical Street Address*

Physical City*

Physical State*

Select

Zip Code (5 digit)*

Location Phone*

Phone

Location Fax*

Phone

Do you have an authorization phone or fax number?

Select

Authorization Phone*

Phone

Authorization Fax*

Phone

Member Information

Are you providing services for a member?*

Select

Authorization #*

What is the member's home state?*

Agency Contact Information

*Who is submitting this request?*

Contact Name*

Contact Email*

*Our preference is company domain email addresses. Non-company related domain such as Gmail and/or Yahoo will be validated.*

Contact Phone Number*

Phone

Additional Comments

I attest that the information provided within this form is true and accurate

I attest*

If you receive an error message, please confirm that all required fields are completed

Send me a copy of my responses

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Agency Information

Site Location Information

Member Information

Agency Contact Information

*If you receive an error message, please confirm that all required fields are completed*

If you receive an error message, please confirm that all required fields are completed