Health Choice Utah & University of Utah Health Plans
Provider Application


This common provider network application is used by Health Choice Utah and University of Utah Health Plans. For ease of administration, provider demographic information and credentialing processes are combined; however, network participation and contracting are determined separately.

Health Choice Utah Provider Network

Indicate if you are interested in participating with Health Choice Utah:

University of Utah Health Plans Provider Networks

Indicate the networks with which you are interested in participating:

*If your clinic or organization provides both physical health and behavioral health services AND you are located within the geography listed, mark both networks.

Note: This application does not apply to the Huntsman Mental Health Behavioral Health Network (HMHI BHN). If you are interested in becoming a participating provider with HMHI BHN, please check out the Behavioral Health Network site.

Completion of this application does not guarantee a contract or participation with Health Choice Utah or University of Utah Health Plans.

Completely describe your services or scope of practice in the space below and/or attach any relevant marketing materials describing your services.
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Sender Information

This information is for the person we should contact if there are any issues with the application.


Provider Information

Please be as accurate as possible when entering the provider information and we'll determine provider eligibility.
  • If you want to contract as a solo provider, please select Solo Provider.
  • If you want to contract as a new group/clinic, please select Group/Clinic.
  • If you want to contract as a facility, please select Facility.
    (Examples of facilities include hospitals, ASCs, home medical supplies/DMEs, home health & hospices)
Complete this form as a...


Organization Information


Organization Questions

Practice licensed to operate in state?
Is Practice Accredited?
Is group hospital based only?
Does Practice submit claims electronically?

Contracting Contact Information


Credentialing Contact Information


Location(s)

Primary Service Location (Location where patients are treated)

Location Information

- or -

Location Address Information

Billing Information

Does the location provide any of the following?

Is the location ADA compliant?
Is the location handicap accessible?
Visual impairment accommodations
Hearing impairment accommodations
Language translation/interpretation
Substance Use Treatment
Is domestic violence support available?
Pediatric Services
Mobile Medicine
Mental Health Treatment
Eating Disorder Treatment
Does this location provide Medication Assisted Treatment (MAT)?
Does the location have age restrictions?
Does the location have gender restrictions?
Does the location have any other restrictions?
Extended hours
Virtual Visits

After Hours Coverage

For hospital facilities with 50 beds or more. Is your organization affiliated with a Patient Safety Organization (PSO)?


Provider agrees University of Utah Health Plans may share provider application and related credentialing information with any group or entity that has delegated or contracted with U of U Health Plans to provide such activities on their behalf. Information cannot be shared for any reason except for provider directory/demographic and credentialing activities.


U of U Health Plans does not discriminate based on race, gender, nationality, age, sexual orientation, the type/cost of treatment or patient in which the provider specializes including providers serving high-risk populations, or in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his, her or their license or certification under state law, solely on the basis of the license or certification.

If you do not receive confirmation of your application within 48 hours, please contact providercontracting@hsc.utah.edu