HMSA Facility and Ancillary Credentialing Application: Fill out & sign online

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Click ‘Get Form’ to open the HMSA Facility and Ancillary Credentialing Application in the editor.
Begin by filling out the 'Facility Practice Locations' section. Indicate whether this is for initial credentialing, adding a new site, or recredentialing. Provide the legal name, parent company, and facility type.
Complete the 'Identify Levels of Care Offered by Facility' section. Select all applicable levels of care and specify if detoxification services are offered.
In the 'Facility Information' section, enter your mailing address, administrative phone number, and federal tax ID number. Ensure all contact information is accurate.
Attach required documents such as accreditation letters, licenses, and insurance policies as specified in the checklist provided within the application.
Review all entered information for accuracy before submitting. Use our platform's features to save your progress or make edits as needed.

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