HPI Online Precertification Form

This form is for precertification of HPI's New England business only, with the following exceptions:

Dartmouth Hitchcock employees and dependents receiving Behavioral Health services call Optum at 844-701-5149
Southcoast Health employees and dependents receiving care in New England: call Conifer at 877-531-1139
Southcoast Health employees and dependents receiving care outside of New England: call United Health Care at 866-569-4345

For employees and dependents of employers located outside of New England, contact HPI's AchieveHealth program at 1-800-432-8421 or check the back of the patient's ID card for the appropriate contact number.

Note: This form is not to be used for provider network exceptions, appeals, or referrals.

1. Submitter Information

Last Name*:

First Name*:

Fax*:

Phone*:

Email:

2. Group Information

Group ID:

Group Name*:

3. Patient Information

Member ID*:

Last Name*:

First Name*:

Date of Birth (MM/DD/YYYY)*:

Gender:

Address*:

City*:

State*:

ZIP Code*:

Phone Number*:

Email:

Relationship to Subscriber*:

3a. Newborn Patient Information (if applicable)

Newborn information not applicable

Last Name:

First Name:

Date of Birth (MM/DD/YYYY):

Gender:

Same Address as in Section 3

Address:

City:

State:

ZIP Code:

Phone Number:

Was the mother discharged?
Yes
No

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1. Submitter Information

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