Provider Information Forms

Individual Practitioners must update the following information through our on-line provider self-service tool at Provider Self Service.

• Patient Acceptance
• Close location(s)
• Add location
• Update Location information (contact phone, staff languages, mailing address, etc.)
• Marketing Specialty
• Hospital Affiliations

Medical groups will complete one (or more) of the forms below to notify us of an address change, new practice location, closed practice, or change to your payment information. Be sure to sign and date the form. Incomplete forms may cause processing delays.

Address Change Form [PDF]
Use this form when you close an existing practice location and move to a new practice location. Be sure to include a future effective date for the address change.

Additional Location Form [PDF]
Use this form when you add a new practice location in addition to your current practice locations.

Change in Provider Panel Form [PDF]
Use this form to change your PCP status or your status about accepting new patients.

Change in Specialty Form [PDF]
Use this form to change your HMSA Marketing specialty. This specialty change will apply to all of your locations and will be displayed in HMSA’s provider directories (unless you have notified HMSA that you do not wish to be listed in the directories).

Closed Location Form [PDF]
Use this form to close one or all of your practice locations (e.g., due to retirement, leaving the state, etc.). If you're closing all of your practice locations, you'll need to give HMSA at least 60 calendar days' written notice to ensure proper continuity of care for your patients.

HHIN+ Documents & Information
Use these forms to request access HHIN+

Hospital Affiliation Form [PDF]
Use this form to change (add/change/terminate) your hospital affiliations.

Payment Change Form [PDF]
Use this form to change your payment (remittance) address, tax ID number, or national provider identifier (NPI) number. Be sure to include a future effective date for the payment change. NOTE: If you change your tax ID or NPI number, we'll terminate your current HMSA contract and provider ID number and will issue a new contract and ID.

PCP Member List Form [PDF]
Use this form if you are a PCP being removed or leaving HMSA's provider network to list impacted members.

Troubleshooting note: If you're having trouble typing in or printing the form from your browser, download it to your desktop and open it using Adobe Reader.

Revision History