Electronic contracting registration

Use this form to add or update details about your legal contract signatory.

All notifications relating to provider agreements are made by email. When documents require signature, DocuSign is used. Contractual documents must be reviewed and signed electronically by the person delegated (the legal contract signatory) to receive contractual notifications and sign provider agreements on behalf of contracted physicians or other health care professionals at your practice.

Your details

First name*

Last name*

Phone number*

Email address*

Effective date of change*

Provider or facility contract information

Are you currently signed up for electronic contracting?*

Yes

Which Regence plan (plan affiliate) are you contracting with?*

Provider first name*

Provider middle name

Provider last name*

Organization name(s)*

Doing business as (DBA)

National Provider Identifier (NPI)*

Organization or clinic NPI*

Tax ID*

Medicare billing number*

Legal contract signatory information

First name*

Last name*

Phone number*

Email address*

We recommend you use an email account dedicated to contracting that remains with the provider instead of an individual’s email account. This will ensure future contractual communications are received regardless of staffing changes.