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HSA: MED 754/DRG 860 Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2017 12/31/2017 Coverage for: Individual / Family Plan Type: This is only a summary.
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01
Open the HMSA Med 754DRG 860 form
02
Read all the instructions on the form carefully
03
Enter your personal information in the designated fields, such as your name, date of birth, and gender
04
Provide your contact information, including address, phone number, and email
05
Fill in your health insurance details, such as your policy number and coverage information
06
Indicate your medical provider information, including their name, address, and contact details
07
Specify the dates and details of the medical services or procedures for which you are seeking reimbursement
08
Attach any supporting documents, such as medical bills or receipts
09
Review the completed form to ensure all information is accurate and legible
10
Sign and date the form
11
Submit the form either in person or by mail to the appropriate HMSA office
Who needs hmsa med 754drg 860?
01
Individuals who are covered by HMSA health insurance
02
Individuals who have undergone medical services or procedures that are eligible for reimbursement
03
Individuals who want to request reimbursement for out-of-pocket medical expenses
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