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 care in New England: call Optum at 844-701-5149
  • Dartmouth-Hitchcock employees and dependents receiving care outside of New England: call United Health Care at 866-569-4345
  • 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

2. Group Information

3. Patient Information

3a. Newborn Patient Information (if applicable)



4. Patient/Member Search