HMA Claim Reimbursement Form

HMA Claim Reimbursement Form

Only 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.
Member, Broker or Both*
Member Name

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

MonthDayYear
DOB
Broker Name

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

MonthDayYear
DOB
Good Phone Number*
For Call BackFormat: 0000000000.
Good Time for Call Back

Hour Minutes

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