Provider Type:*

Professional Hospital Ancillary

Office Type:*

Practice Location Administrative Office Central Billing Office Billing Agency

User First Name:*

User Last Name:*

Group/Practice Name:

Billing Agency Name (if applicable):

Phone #:*

Fax #:

Email Address:*

Title:

Primary Site Zip Code:

TIN:*

Group NPI:*

I have the authority to perform the duties of Super User for my practice.*
(Super Users have the authority to create, terminate and manage access for the users in their practice.)

I am requesting access to multiple Tax ID Numbers.
(This will require manual setup. A Health Partners Plans representative will be in touch to help expedite your setup.)

Name of person who physically completed this request form:

HP Connect registration will additionally register you for our electronic provider communication system, HP Insider. Through HP Insider you will receive routine communications from Health Partners Plans regarding changes to policies and procedures, new initiatives and other valuable information.