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Contact information form pdf 2026
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- Click ‘Get Form’ to open the Contact Information Form in the editor.
- Begin by filling out Section 1 with the Health Plan Issuer (HPI) Name(s) and HPI FEIN Number. Ensure accuracy as this information is crucial for identification.
- In Section 2, provide the HPI Contact Information. Enter the contact's first name, last name, middle initial, email address, phone number, and job title. If the contact is not a person, enter 'N/A' where applicable.
- For Section 3, select all applicable HPI Contact Roles. Be mindful that only specific roles can be assigned to non-person contacts.
- Finally, complete Section 4 by providing details of the manager or officer authorizing access. Include their name, email, title, phone number, and effective date of authorization.
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ohio contact
This form must be used by the primary contact to (1) replace or update the primary contact on the vendor record or (2) make changes to non-primary contacts
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