Follow the steps to complete the application online successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the facility information section, including the legal name, business name, federal tax identification number, NPI, and contact details for the administrator.
3. Provide the location address information. Include the physical address, building name if applicable, city, state, and ZIP code.
4. Complete the mailing address information, ensuring the correct address is filled out for correspondence.
5. Indicate the facility or ancillary provider type by selecting the appropriate categories relevant to your organization.
6. Fill out the facility/program license section. Include the necessary licensing information and agency details, along with dates pertinent to licensing.
7. Answer questions about Medicare status, specifying whether the facility participates in the Medicare program and providing the necessary details.
8. In the professional liability coverage information section, provide details about insurance coverage, policy number, and contact information for the issuing agency.
9. Address the restrictive action questions truthfully, providing explanations for any 'Yes' responses as needed.
10. If applicable, complete the accredited facilities or non-accredited facilities sections, providing necessary certification or documentation.
11. Fill out the attestation section, affirming that the information provided is accurate and complete before signing electronically.
12. Review all the entered information for accuracy. After ensuring all fields are properly filled, save your changes, download, print, or share the completed form as required.

Complete your HI HMSA Facility/Ancillary Credentialing Application online today to ensure timely processing.