Saturday, September 23, 2017
 

Provider Contact Form

Please fill out and submit the form below to contact the Electronic Transaction Services Outreach team.
* - denotes a required field

Provider Full Legal Name *
Business Entity Name
Requestor's Name (you) *
Supervisor/Manager's Name
Address 1 *
Address 2
City *
State *
Zip Code *
Phone Number (do not include dash) * (
Phone Extension Number x
Fax Number (do not include dash) (
E-mail Address *
 
HMSA Provider ID(s)
NPI (Type 1) *
NPI (Type 2)
 
Internet Service Provider
Web Browsers Available
(check all that apply)



 
Which Electronic Products are you interested in?
(check all that apply)




Third Party Billing Company
Name
Address
Phone Number (do not include dash) (
 
Additional Comments


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