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Click ‘Get Form’ to open the HMSA Credentialing Application in the editor.
Begin with Section I: Facility Information. Fill in the Legal Name, Business Name (if applicable), Federal Tax Identification Number, and NPI. Ensure all fields are completed accurately.
Continue to provide contact details for the Administrator, including their email and phone number. Don’t forget to include the Medical Director's information if applicable.
In Section II, enter the Physical Address of your facility. Confirm if ADA accommodations are available by checking 'Yes' or 'No'.
Proceed to Section III for Mailing Address Information. This may differ from your physical address; ensure accuracy.
Complete Sections IV through XI as required, ensuring you attach any necessary documentation such as insurance certificates or accreditation letters.
Finally, review all entries for completeness and accuracy before electronically signing the form at the end.
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