HPHConnect Enrollment Form

HPHConnect Provider Enrollment Form

You are a Provider Organization completing initial registration
You need additional access (Add new or missing TIN, NPI, etc. to existing Provider account)
You are a 3rd Party Organization requesting initial or additional access
Yes
No (Select to add providers to existing 3rd Party account)
Be Prepared: If you are a 3rd party or non-contracted/out-of-area provider organization (outside of New England), you will need to have a contact with signatory authority for your organization (e.g., Security Officer, Director, VP, Owner or Provider) available to digitally sign this form.