First Tier Contact Information

Organization Name*

Organization Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Organizations's Authorized Representative*

Organization's Authorized Representative Phone Number*

Organization's Authorized Representative Email Address*

Section I.

Downstream Entity (Subcontractor)

We Do Not Have Subcontractors
Our organization does not have any subcontractors that perform administrative and/or healthcare services for our Medicare beneficiaries.

If you check the box above, you may click submit. If you do use subcontractor(s), please provide information on each below before clicking submit.

Section II.

Downstream Entity (Subcontractor) 1

First Subcontractor Name*

Subcontractor Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Describe First Subcontractor Functions as They Relate to Providing Administrative and/or Healthcare Services on Behalf of HPP to Our Medicare Beneficiaries.*

Downstream Entity (Subcontractor) 2

Second Subcontractor Name*

Subcontractor Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Describe Second Subcontractor Functions as They Relate to Providing Administrative and/or Healthcare Services on Behalf of HPP to Our Medicare Beneficiaries.*

Downstream Entity (Subcontractor) 3

Third Subcontractor Name*

Subcontractor Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Describe Third Subcontractor Functions as They Relate to Providing Administrative and/or Healthcare Services on Behalf of HPP to Our Medicare Beneficiaries.*

Downstream Entity (Subcontractor) 4

Fourth Subcontractor Name*

Subcontractor Address, Line 1*

Line 2

City*

State*
(please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code*

Describe Fourth Subcontractor Functions as They Relate to Providing Administrative and/or Healthcare Services on Behalf of HPP to Our Medicare Beneficiaries.*