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Form physician information 2026
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- Click ‘Get Form’ to open the Physician Information Form in the editor.
- Begin by entering your personal details in the 'Physician Information' section. Fill in your name (last, first, middle) and degree. Select your gender from the options provided.
- Input your Group NPI number and CAQH ID number. Ensure that HAP is added to your CAQH registry for proper credentialing.
- Specify your specialty and indicate whether you participate in Medicare by selecting 'Yes', 'No', or 'Pending'. If you select 'No', please stop and resubmit once you have obtained a Medicare number.
- Complete the 'Primacy Office Information' section with your office address, including street address, suite number, city, state, phone, fax, and ZIP code.
- Fill out the billing information accurately. Include the bill-to name, billing address details, tax identification number, and billing contact person.
- Finally, review all entered information for accuracy. Sign and date the form in the consent section before submitting it to provider_development@hap.org.
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See more form physician information versions
We've got more versions of the form physician information form. Select the right form physician information version from the list and start editing it straight away!
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2017 | 4.8 Satisfied (149 Votes) |
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