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Get HMSA Provider Enrollment and Credentialing Application Form Instructions for Individual Provider

and contract effective date will begin once HMSA makes a decision on your credentialing status. Prior to the credentialing approval date, you may register as a non-participating provider. I. Personal Information Legal Name 1. First: Provider’s first name. 2. Middle: Provider’s middle name. 3. Last: Provider’s last name. 4. Suffix: (e.g., Sr., Jr., II, etc.). 5. Title: (e.g., M.D., D.O., Ph.D., APRN, etc.). 6. Gender. 7. Date of Birth. 8. Social Security Number. 9. Individual NPI. • Nat.

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