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CLOSED LOCATION FORM To close one practice location or all locations.

NOTE: According to your participating provider agreement with HMSA, you need to give HMSA at least 60 days written notice if you’re closing all of your practice locations to ensure proper continuity of care for your patients.

If you’re closing a practice location because you’re moving to a new location in Hawaii, please use the Address Change Form.

Provider name: Social Security no. (last four digits only):

National Provider Identifier (NPI) no.: (Indicate your individual NPI, not your clinic or group’s NPI.)

HMSA Provider ID no.:

Reason for closure: Last date you’ll see patients at this location:

Name of primary care provider (PCP) that members should be reassigned to (if applicable): Note to PCPs: Per Hawaii Revised Statutes (HRS) §431-26-104(l)(3), effective January 1, 2019, all HMSA members who are patients of a PCP must be notified no later than 30 days after the provider gives or receives notice of leaving HMSA’s network. To notify members, please provide us with a list of these members by completing and signing the PCP Member List Form located in the Provider Resource Center at hmsa.com/portal/provider/PCP_Member_List_Form.pdf. PCPs need to provide the line of business, date of birth, subscriber ID, and department code of each impacted member. Instructions for submitting the form are on the last page.

Street address of closed location:

Location provider no.: Last date you’ll see patients at this location:

Reason for closure:

Name of PCP members should be reassigned to (if applicable):

Street address of closed location:

Location provider no.: Last date you’ll see patients at this location:

Reason for closure:

Name of PCP members should be reassigned to (if applicable):

Street address of closed location:

Location provider no.: Last date you’ll see patients at this location:

Reason for closure:

Name of PCP members should be reassigned to (if applicable): Note: If you’re closing additional locations, please complete this information for each location closing. Attach copies of this page if necessary..

Address:

City: State: ZIP: .

(Complete this section if you’re closing all locations because you’re retiring, leaving the state, etc.)

(If this is a group-contracted location, please have the group submit the closure request.)

(Please complete if applicable. If you’re closing all of your locations, please leave a forwarding address here.)

FOR HMSA USE ONLY

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Provider signature (Signature and date is required to process request.)

If I’ve signed this Closed Location Form electronically, it means I acknowledge and agree to the terms of the form and indicate this by typing my name below as my electronic signature, executed and adopted by me with the intent to sign this document. In other words, typing my name as an electronic signature indicates I acknowledge and agree to the terms of this form just as a handwritten signature would on a traditional paper form.

Signature Date

Mail: Provider Data Administration, KLCR-PDA HMSA P.O. Box 860 Honolulu, HI 96808-0860

Email: provider_data@hmsa.com Fax: 948-8210 on Oahu Questions?: Call 952-7847 on Oahu or 1 (800) 603-4672, ext. 7847, toll-free on the Neighbor Islands

1115-71352 Rev 1/19

FOR HMSA USE ONLY