Follow the steps to complete your application successfully.

1. Select the ‘Get Form’ button to access the HI HMSA Facility/Ancillary Credentialing Application form and open it in your preferred editor.
2. Begin filling out the Facility Information section. Enter the legal name, business name (DBA), NPI, federal tax identification number, and contact details of the administrator, including email, phone, and fax.
3. In the Location Information section, provide the address, building name (if applicable), and indicate whether the facility has handicap accessibility by selecting 'Yes' or 'No'.
4. Complete the Mailing Address Information section by providing the mailing address and any applicable building name.
5. Select the Facility/Ancillary Credentialing Provider Type that applies to your facility by checking the relevant box.
6. For the Facility Program License section, provide the license number, licensing agency, and all relevant dates pertaining to the license.
7. Indicate the Medicare status of the facility. If applicable, provide the Medicare number and date of certification.
8. In the Participating Programs section, indicate participation in the preferred provider plan, health maintenance organization, and any other relevant programs by checking 'Yes' or 'No'.
9. Complete the Professional Liability Coverage Information section by answering the questions regarding liability insurance and attach the necessary documents.
10. Depending on whether the facility is accredited or nonaccredited, fill out the appropriate sections by providing documentation as needed.
11. If applicable, complete the Behavioral Health Facility section, detailing accreditation and on-site survey information.
12. Review all information for accuracy. Once completed, save changes, and utilize the options to download, print, or share the completed form.

Complete your HI HMSA Facility/Ancillary Credentialing Application online today to ensure your facility is properly credentialed.