Electronic Claims Submission Request Form
Email the form to HSMSOEDI@HealthsourceMSO.com
Standard processing time is 1-3 business days
Office Ally, Inc | PO Box 872020 | Vancouver, WA 98687 | (360) 975-7000
HEALTH SOURCE MSO (HSMSO)
PRE-ENROLLMENT INSTRUCTIONS
WHICH FORM(S) SHOULD I DO?
WHERE SHOULD I SEND THE FORM(S)?
WHAT IS THE TURNAROUND TIME?
Electronic Claims Submission Request Form
Instructions
Electronic Claims Submission is only available to contracted providers
ALL FIELDS ARE REQUIRED
Form must be filled out and signed by an authorized representative for the provider
Please email all completed forms to HSMSOEDI@HealthsourceMSO.com
Once the provider has been approved, HSMSO will email the contacts below with instructions on how to submit
electronic claims to HSMSO
Vendor Information
Provider Name:
Provider Tax ID:
Provider NPI:
Which IPA/Hospital is the Provider Contracted With:
Authorized Representative Information
Title:
Phone Number:
Email:
EDI/Technical Contact Information
Title:
Phone Number:
Email:
Claim Submission Information
Claim Submission Type?
UB04
CMS 1500
Will This Provider Submit Attachments?
YES
NO
Authorized
Signature: Date:
click to sign
signature
click to edit