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  • Hma Prior Authorization Form

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TION FORM Referring Provider or Primary Care Physician: Address of Referring Provider or Primary Care Physician: Name of Office Contact Person: Phone: Fax: PATIENT INFORMATION Patient Name: Date of Birth: Sex: F M Patient ID #: Primary Insurance: Patient s Phone: Address: Other Insurance (Third Party Liability, Workmen s Compensation): Date of Injury: TREATING SPECIALIST OR TREATING FACILITY INFORMATION Name of Treating Specialist or Facility: Address of Treating Special.

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We accept electronic claims through Availity using payer ID HMA01. You can also submit claims via mail to our claims address P.O. Box 85008 Bellevue WA 98015 or fax at 1-866-458-5488. What is HMA's holiday schedule?

The Health Matching Account (HMA®) is a non-qualified, medical benefit savings plan that pays for most out-of-pocket, medical expenses that your health insurance and Medicare does not cover.

We accept electronic claims through Availity using payer ID HMA01.

Who is responsible for obtaining prior authorization? The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider.

The Health Matching Account (HMA®) is a non-qualified, medical benefit savings plan that pays for most out-of-pocket, medical expenses that your health insurance and Medicare does not cover.

You will need to call 702-735-5525 and request an account with a log in and password for HCRnet. Let them know you will be using it to send electronic claims directly to HMA, Payer ID 86066.

A: Submit claim/receipt copies to: Hawaii Mainland Administrators Attn: Claims Department, 1600 W Broadway Rd., Suite 300, Tempe, AZ 85282. Claims and receipts must include Patient name and ID#, Provider TAX ID#, Date Of Service, diagnosis, and procedures rendered.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232