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Get Hmsa Travel Assistance Request Form
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How to fill out the Hmsa Travel Assistance Request Form online
Filling out the Hmsa Travel Assistance Request Form online is a streamlined process that requires careful attention to detail. This guide provides step-by-step instructions to help you complete each section accurately.
Follow the steps to fill out your form successfully.
- Press the ‘Get Form’ button to retrieve the Hmsa Travel Assistance Request Form and open it for editing.
- In section A, provide your member information. Fill in your membership number, the patient’s name, companion's name if the patient is 17 years old or younger, date of birth, and specify your relationship to the companion.
- Continue to section B, where you will enter the ICD-9-CM diagnosis code(s). Ensure accuracy in the codes to avoid delays.
- In section C, detail the procedure, service, or treatment information. Enter the CPT/HCPCS code(s), the date of your appointment, and the time of your appointment.
- Complete section D by filling in the requesting provider information, including their name, provider ID, address, phone number, and fax number. Also, provide the servicing specialty provider's information.
- In section E, clarify the reason for the referral to a specialist provider. Provide specific details on why the patient cannot see an on-island specialist.
- Review the entire form for accuracy and completeness. Once satisfied, you can save your changes, download, print, or share the completed form as needed.
Complete your documents online today for a hassle-free experience.
A travel request form is a document you complete to request authorization for travel expenses. When you need to go on a business trip, this form helps your organization track and approve necessary travel arrangements. The Hmsa Travel Assistance Request Form provides a structured way to submit your travel needs, ensuring that all essential details are captured for a seamless approval process.
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