Revised 06/14/2021HCAS Provider Enrollment FormDATECOMPLETED BYTELEPHONEEMAIL OF PERSON COMPLETING FORMSection 1: Provider InformationM Provider First NameMiddle InitialProvider Last NameDegree/TitleSocial.
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How to fill out the HCAS Provider Enrollment Form online
Completing the HCAS Provider Enrollment Form is an essential step for providers seeking enrollment. This guide will walk you through the process of filling out the form online, ensuring that you provide all necessary information accurately.
Follow the steps to fill out the HCAS Provider Enrollment Form online effectively.
- Press the ‘Get Form’ button to obtain the form and open it in the appropriate editor.
- Begin by completing Section 1, which includes the provider's information. Input your first name, middle initial, last name, degree or title, social security number, email address, and date of birth. Ensure to select your gender and indicate the languages you speak.
- Continue in Section 1 by detailing your specialty and certification status. If you are board certified, indicate 'Yes' or 'No', and similarly address whether you are eligible for certification if not board certified. Provide your CAQH ID and National Provider Identifier (NPI), as well as your primary and secondary hospital affiliations.
- In Section 2, provide your primary practice information. Specify the practice name and primary address, indicating whether patients can make appointments at this location. If it is not your mailing address or credentialing address, ensure to complete the last page.
- Document your payment information in Section 3, including your payee name, tax identification number, and payment address. Make sure to provide contact details like phone number and email.
- Section 4 covers other provider information. Specify your status regarding accepting new patients and indicate any practice restrictions. Provide Medicare participation status and any additional requested numbers.
- In the final step, review the submission information provided in Section 5 so you know where to send your completed form. Make sure all information is correct and complete.
- Once you have filled out all sections, save any changes made. You can then download, print, or share the completed form as necessary.
We encourage you to complete the HCAS Provider Enrollment Form online to ensure a smooth enrollment process.
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