.: Health Utah :.

Provider Application

Thank you for your interest in joining the Health Utah Provider Network. To begin, we would like you to fill out this short application letting us know who you are. A representative of Health Utah will contact you shortly after it is submitted.

Provider Tax ID
National Provider Identifier (NPI)
CAQH Number (Optional)

Provider Information
Provider/Facility Name
Doctors Name (last, first, middle)	,
Specialty

Location Information
Physical Address		Billing Address
Address		Address
City		City
State		State
Zip		Zip
Contact Information
Contact Person
Phone Number
Email Address