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ATTACHMENT D Denver Health Medical Plan, Inc. 2015 CSA DEMO Member Reimbursement Form Member s Name: Mailing Address: Member s I.D. Number: ORTHOTICS: L$3000100.00 *Maximum benefit per calendar year*
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What is csa dhmo reimbursement form?
The csa dhmo reimbursement form is a document used to request reimbursement for expenses related to dental treatments covered under a Comprehensive Dental Plan (CDP), also known as DHMO.
Who is required to file csa dhmo reimbursement form?
Any member or dependent of the CDP who has incurred eligible dental expenses and wishes to seek reimbursement is required to file the csa dhmo reimbursement form.
How to fill out csa dhmo reimbursement form?
To fill out the csa dhmo reimbursement form, the member needs to provide their personal information, details of the dental treatment received, and submit receipts or invoices showing the incurred expenses.
What is the purpose of csa dhmo reimbursement form?
The purpose of the csa dhmo reimbursement form is to request reimbursement for dental expenses covered under the CDP, allowing members to recover part of the cost incurred for eligible treatments.
What information must be reported on csa dhmo reimbursement form?
The csa dhmo reimbursement form requires information such as the member's name, member ID, treatment details, date of treatment, provider information, and the total amount of expenses incurred.
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