Program Enrollment

Address: 3330 Cumberland Blvd, Suite 500, Atlanta, GA 30339
Telephone: 770-953-3026
Fax: 770-771-5945

Program Enrollment

Enrollment with HPS is easy. If you have any questions or concerns, please contact our office at 770-953-3026 for assistance.

Complete and submit the online HPS enrollment form (see below), choose the programs you need, and sign the online member disclosure agreement.

A member of our HPS team will send you a follow-up email to verify the programs you have selected and provide you with the necessary forms to enroll.

Business Information

Business Name:

Billing Address
Street:
City:
State:
Zip Code:

Primary Shipping Address - If different than the Billing Address - No PO Boxes
Street:
City:
State:
Zip:

Primary Phone Number:
Website Address:
Class of Trade:
If "Other", please specify:
Number of Employees:
Number of Locations:

Contact Information

Program Participation

Reference Laboratory Services

Who is your current provider of lab services?


What is your account number with the current provider?


Please provide the name of your current lab service representative.

Please provide the phone number of your current lab service representative.

Please provide the email address of your current lab service representative.


Expected annual lab volume: $

What is your current EMR platform?

Do you have an in-house phlebotomist?
Yes No
What is your practice specialty (if more specific than Class of Trade provided)?

Disclosure Agreement

I have read and understand the HPS Member Disclosure Agreement. By entering my name in the signature box below, I acknowledge receipt and accept the terms of this Agreement as a condition of participation.

Signature:

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