Get Hi Pr E-03 2013

The HI PR E-03 form is essential for medical providers seeking participation with the HWMG provider network. This guide will help you accurately and comprehensively complete the form online, ensuring all sections are filled out correctly.

Follow the steps to fill out the HI PR E-03 form online.

1. Press the 'Get Form' button to access the HI PR E-03 form. This will allow you to open the document in an editable format.
2. Begin with Section 1: General Practice Information. Fill in your National Provider Identifier Number and Taxpayer Identification Number accurately. Provide the Business Name as it appears on your W-9 and specify the Practice Name if it differs. Choose the Type of Practice that best describes your setup.
3. Provide your Primary Practice Location details, including the street address, city, state, and zip code. Indicate if the mailing address is the same by selecting 'Yes' or provide alternate information if 'No'.
4. Complete the sections related to Billing Information, including the e-mail address, appointment phone number, and fax number. Indicate whether these contact details apply to billing as well.
5. Enter the Office Contact Person's information, including their title. Specify to whom checks should be made payable and list your office hours for each day of the week.
6. If you have additional practice locations, fill out the Additional Practice Location section. Repeat the necessary information as provided in Section 1.
7. Answer the Practice Location Questions carefully. Indicate if staff members speak languages other than English, whether you share office space, and confirm your practice’s compliance with the Americans with Disabilities Act.
8. In Section 2: Practitioner Registration, provide the required details for each practitioner. This includes their last name, first name, title/degree, and professional licenses.
9. Respond to the Practitioner Questions honestly, particularly concerning any malpractice history. Include this information on a separate sheet if required.
10. Finally, review all entered details for accuracy. Sign and date the application. Make sure to attach any required documents, such as proof of liability insurance.
11. Once completed, save all changes, download a copy for your records, and print the form if necessary for mailing or faxing.

Complete your HI PR E-03 application form online today and ensure your participation in the HWMG provider network.