For Provider - Healthcare Networks of America

Provider*

Full Address*

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

Provider Renewal Form

Annual Credentialing Fee $145

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

Section Break