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Click ‘Get Form’ to open the HMSA Provider Enrollment and Credentialing Application in the editor.
Begin by filling out your Personal Information. Enter your legal name, including first, middle, last names, suffix, title, gender, date of birth, social security number, and individual NPI. Ensure you have your NPI confirmation ready if applicable.
Proceed to Other Names Known As section if applicable. Fill in any previous names along with languages spoken.
Complete the Application Contact Information section by providing your contact details including phone number and email address.
Indicate your HMSA Marketing Specialty and check any additional qualifications relevant to your practice.
Fill out the Mailing/Correspondence Address Information accurately as this will be used for all communications from HMSA.
Continue through each section including Primary Location Information and Payment Address ensuring all required fields are completed.
Finally, review all information for accuracy before signing the application in the Attestation section.
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Submit your request to HMSA: Update your address on My Account . My Account gives you access to certain plan information and allows you to perform certain online requests. Mail your request to. Membership Services. P.O. Box 860. Honolulu, HI 96808. Call HMSA Customer Relations .
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