Organizational/Provider Contracting Application


University of Utah Health Plans Provider Networks

Indicate the networks with which you are interested in participating:

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 contact Jessie.Konate@hsc.utah.edu.

Completion of this application does not guarantee a contract or participation with 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




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?





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