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Thursday, October 31, 2024
Provider Contact Form
Please fill out and submit the form below to contact the Electronic Transaction Services Outreach team.
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- denotes a required field
Provider Full Legal Name
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Business Entity Name
Requestor's Name (you)
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Supervisor/Manager's Name
Address 1
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Address 2
City
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*
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State
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*
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Zip Code
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*
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Phone Number (do not include dash)
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(
)
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*
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Phone Extension Number
x
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Fax Number (do not include dash)
(
)
*
*
E-mail Address
*
*
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HMSA Provider ID(s)
NPI (Type 1)
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*
NPI (Type 2)
Internet Service Provider
Select...
Oceanic
Hawaiian Telecom
Other
No Internet Access
Web Browsers Available
(check all that apply)
Internet Explorer - version 7 or higher
Chrome
Safari
Firefox
Which Electronic Products are you interested in?
(check all that apply)
HHIN (Member Verification and Benefits Portal)
EDI - HMSA eClaims Online through HHIN
EDI - Use a clearinghouse or other billing system
ERA (Electronic Remittance Advice)
EFT (Electronic Funds Transfer)
Third Party Billing Company
Name
Address
Phone Number (do not include dash)
(
)
Additional Comments
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