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
##########Format: 0000000000.
Reason of Call
Member, Broker or Both
Member Name

First NameLast Name
Member ID (If Available)
5 DigitsFormat: 00000.
Member Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDOB
Broker Name

First NameLast Name
Broker ID (If Available)
10 DigitsFormat: 0000000000.
Broker Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDOB
Good Phone Number
For Call BackFormat: 0000000000.
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: