Utah Contract Request Form

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 30 business days to analyze the form and make a determination if the contract process will commence. Failure to accurately complete the form will significantly extend this processing time. We will outreach to the contact person listed once a review of your data is completed.

Provider Credentialing Rights

During the credentialing process, Ambetter Health obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling us at 855-688-6589.

Contact Information

Provider Type

Select your provider type. required *
Do you bill on a UB or a 1500 form? required *

Product Interest

Select the products you want to participate in. required *

Provider Information

Applying as: required *
Is this your primary specialty? required *

Provider Identification Numbers

Review & Submit