Contact information form pdf 2026

1. Click ‘Get Form’ to open the Contact Information Form in the editor.
2. 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.
3. 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.
4. For Section 3, select all applicable HPI Contact Roles. Be mindful that only specific roles can be assigned to non-person contacts.
5. 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.

Start using our platform today to easily fill out your Contact Information Form for free!