Provider Intake Form

Request Type

Enrollment Status

Provider Information

Group Name/Facility Name/Organization Name

Address

Zip

City

State

Credentialing Email Address

HPSM will send the Online Credentialing Application to this email.

Phone Number

Fax Number

Individual/Provider NPI

Individual/Provider Tax ID

Provider Group NPI

Provider Group Tax ID

Group Name

Primary Specialty

Secondary Specialty

Primary Taxonomy Code

Secondary Taxonomy Code

Submitter Contact Information

Contact Name

Contact Direct Line (Phone)

Contact Email

Additional Email to Notify

At which hospital do you have privileges? Please list the hospital(s).

Each physician that renders to group practice must have admitting privileges or proof of a coverage arrangement.

Other Hospital(s)

Do you offer telemedicine and/or telehealth?

Yes No

Do you have a license in California?

Yes No

Provider License #

Do you provide services In-Home (Place of Service Code 12)

Yes No

Have you completed the Provider Self-Registration process for the CalEVV (electronic visit verification) system?

Yes No

Date of CalEVV Registration Complete

Health Equity Questions

The purpose of this questionnaire is to ensure new providers align with our values and are committed to delivering equitable care to the Medi-Cal population. The answers to this questionnaire will help our HPSM staff determine if a provider requires additional support or training, such as assistance with implementing CLAS or establishing interpreter services, to better serve our members.

Do you have experience working with Medicaid members or have you contracted with other Medi-Cal managed care plans?

Yes No

Do you train your staff in diversity, equity, and inclusion (DEI)?

Yes No

If no, would you be willing to undergo our required DEI training provided by HPSM?

Yes No

Do you offer culturally and linguistically appropriate services (CLAS) training for your staff?

Yes No

If no, would you be willing to undergo CLAS training offered by HPSM?

Yes No

Do you have a process or workflow for identifying and documenting the language preferences of your patients?

Yes No

Do you have experience using interpreter services?

Yes No

Do you have a system in place for matching interpreters with customers based on language or dialect?

Yes No

Do you offer ASL and deaf interpretation?

Yes No

Are you willing to use HPSM’s interpreter services?

Yes No

In which languages do you offer patient materials?

Other Languages

Are your materials written at a sixth grade reading level?

Yes No Unknown

Provider Intake Form

W9

HPSM Pre-Screening Roster

Proof of Medi-Cal Enrollment

Proof of Medicare Enrollment

Provider Information

Submitter Contact Information

Health Equity Questions