Get Hap Physician Information Form 2017-2025

Completing the HAP Physician Information Form accurately is essential for maintaining up-to-date records in the Council of Affordable Quality Healthcare ProView® profile. This guide provides clear instructions on how to fill out the form online to ensure your credentials are correctly documented.

Follow the steps to fill out the HAP Physician Information Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the supervising physician's name and tax ID. This section is specifically for physician assistants and nurse practitioners, so ensure you provide accurate details.
3. Complete the physician information section by filling in your name (last, first, middle) and degree while selecting the appropriate gender option.
4. Provide your group NPI number and CAQH ID number, ensuring HAP is listed in your CAQH registry.
5. Indicate your specialty and confirm your participation in Medicare. If you do not participate, you must stop here and resubmit once you acquire your Medicare number.
6. Fill in the primary office information, including street address, suite number, city, state, phone, fax, and ZIP code.
7. Include your email address, hospital affiliation(s), and billing information. This should detail the bill-to name, billing address, and contact information.
8. Ensure you attach a current W-9 form. If this is not included, you must stop the process and obtain the W-9 before resubmitting.
9. Sign and date the form to affirm that all information is true and accurate. Enter your printed name and title before submission.
10. Submit the completed form to provider_development@hap.org. You can save changes, download, print, or share the form as needed.

Complete your HAP Physician Information Form online today to ensure your information is accurate and up-to-date.