HMS Self Registration: HMS Provider Profile
User Account Information:

First Name:
Last Name:
Title/Position:
Phone:
Phone Ext:
Email:


Additional Users:

Please include the following information for each user: Full Name, Title, Phone/Ext, Email


Provider Registration Info:


State:
Medical Provider Number(s) as comma separated list:
Provider Name:

Are you a long term care provider?
Yes
No

Requested Application Access:
LTC Financial Review
LTC Contract:
Basic Disallowances
Provider Overpayment Reporting
Program Integrity
CID:
AR Claim Review
Referral Database
COBManager


Add      Please click Add if you want to register providers for additional states
 
Click Submit to submit request or Cancel to discard changes Submit Cancel