To ensure claims payments for HMSA participating dentists are processed quickly and efficiently and to help keep our online provider directories up-to-date, we ask that you please verify that the information listed for your practice is accurate. If you need assistance completing any of the forms below, please contact your Dental Network Manager.
Complete this form if you change an address, patient status, or contact information regarding a practice with which you’re affiliated. It can also be used to close an affiliation under an existing practice location and move to a new practice location. If changes apply to more than one location, please use the “Multi Location Change form.”
Use this form when you need to add/term an affiliation to multiple locations at one or more practices. Copies of the form may be printed if more than four (4) locations are being updated at one time. If you’re closing all of your practice locations, you’ll need to give HMSA at least 30 calendar days’ written notice to ensure proper continuity of care for your patients.
Complete this form to change your payment (remittance) address, taxpayer name, tax ID number, or national provider identifier (NPI) number of an existing practice you are currently affiliated to. If you are adding a location that we don’t have in our system, please complete an Add Location form.
Complete this form to change your dental specialty. The change will apply to all of your locations and will be displayed as your primary specialty in HMSA’s provider directories (unless you notify HMSA that you don’t wish to be listed in the directories).
Printing issues? If you have trouble filling out or printing a form from your browser, download it to your desktop and open it using Adobe Reader.
If you or someone you know are interested in becoming a participating HMSA Dental provider, please visit the Join Our Dental Network page for more information.
We want to help you help your patients. Feel free to call us with any questions or feedback.
