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Home
Health Plan List
Resources
Contact Us
Apply
For Facility (PDF)
For Facility (Online)
For Provider (PDF)
For Provider (Online)
Renew
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For Provider
Provider Renewal Form
Provider
*
Full Address
*
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Armed Forces Americas
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State
ZIP Code
Phone Number
*
Fax Number
*
Website:
Credentialing Contact
Credentialing Contact Email
Doctor/Provider Email
Federal Tax ID Number
National Provider Identifier (NPI) Number
Malpractice Carrier
Exp.
State License Number
Exp.
DEA Certificate Number:
Exp.
Annual Credentialing Fee $145
Check #:
Untitled
MasterCard/Visa
American Express
Card Number:
Exp. Date:
3 or 4 digit security code:
I authorize the above card to be charged for my credentialing fee.
To obtain a copy of our fee schedule/health plan list please e-mail us at providerrelations@hna-net.com
You consent to us contacting you using all channels of communication and for all purposes. We will use the contact information you provide to us. This may include text messages, automatic telephone dialing systems, prerecorded voice and/or fax. We do not sell or distribute our lists. This information is used for internal purposes only.
Signature
*
Date
*
PO BOX 71717, PHOENIX, ARIZONA 85050 VOICE 877-311-3338 FAX 602.485.3100
WWW.HNA-NET.COM
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