HI-MPAL Provider Registration Form

HI-MPAL Provider Registration Form
Primary Care Providers we ask that you take a moment to complete this registration form to access HI-MPAL services - it will take just one minute! The information collected will remain confidential and not be shared outside of HI-MPAL program.
Provider Full Name

First NameLast Name
Name of referring clinic, if applicable
Provider Discipline
If Other, please specify
Primary Setting of Work
If Other, please specify
National Provider Identifier (NPI)
10-digit number
Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Practice Phone Number

Country CodeArea CodePhone Number
Practice Fax Number

Country CodeArea CodePhone Number
Email Address
Provider call back number (cell phone preferred)

Country CodeArea CodePhone Number
Should be Empty: