HMA Non Claim Reimbursement Form

Other Than Claim Reimbursement
Inbound Call:

Thank you for calling HMA Services!
This is _________, How may i help you?

Outbound to Missed Calls:

This is _________ calling back from HMAS!
How are you doing today?
Phone Number from Dialer*
##########
Reason of Call*
Member, Broker or Both*
Member Name

First NameLast Name
Member ID (If Available)
5 Digits
Member Date Of Birth

MonthDayYear
DOB
Broker Name

First NameLast Name
Broker ID (If Available)
10 Digits
Broker Date Of Birth

MonthDayYear
DOB
Good Phone Number*
For Call Back
Address

Street Address

Street Address Line 2

CityState

Zip Code
Good Time for Call Back

Hour Minutes

AM/PM Option
Manager in 24 hours?*
Notes:
Agent*
Should be Empty: