Get Hsmso And Aco Access Application Form

Completing the HSMSO And ACO Access Application Form online is a straightforward process that ensures users can gain necessary access to health services. This guide provides clear and detailed steps to assist you in filling out the form accurately.

Follow the steps to successfully complete the application form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Hospital/IPA/Entity Name' field, enter the name of the hospital or entity for which you are requesting access. This field is mandatory.
3. Provide the NPI number related to the facility in the corresponding field. This is a critical numeric identifier required for processing your application.
4. Enter the Tax ID number associated with the entity in the appropriate field. This information is essential for verification purposes.
5. In the 'Account requested for (User)' section, fill in the first and last name of the person who will be using the account.
6. Complete the contact information by providing a phone number, fax number, and email address. Ensure that this information is accurate for effective communication.
7. Select the appropriate access type by checking either the ‘MSO/Managed Care’ or ‘Accountable Care Organization (ACO)’ box.
8. Add your signature and the date in the designated area to verify your request.
9. Requested by section must include the manager's printed name, their signature, and the date to indicate approval for the access request.
10. Once you have filled out all required fields, save the changes you made. You can then download, print, or share the completed form as needed.
11. Finally, scan the completed form and submit it to the provided email address: portalaccess@healthsourcemso.com.

Begin filling out your HSMSO and ACO Access Application Form online today to gain the necessary access.