Home
About HCA
Contact HCA
Contact us - Apple Health (Medicaid) client
Please correct the following errors, or contact the Health Care Authority Customer Service Center at 1-800-562-3022:
All fields with a red asterisk is a required field and must be completed in order to submit.
Select Topic:
Email Address:
Services Card Number:
Application ID:
First Name:
Last Name:
Date of Birth:
(ex: mm/dd/yyyy)
ZIP Code:
(ex: 98444 or 98444-2294)
Residential County:
Select Subtopic:
Insurance Name:
Insurance Address:
Insurance Phone:
Subscriber Name:
Subscriber Date of Birth:
(ex: mm/dd/yyyy)
Date Insurance Ended:
(ex: mm/dd/yyyy)
Name of Billing Provider:
Account Number:
Phone Number of Billing Provider:
Dates of Service:
Billed Amount:
Select Subtopic:
If you require 1095-B to be reprinted for multiple tax years, please add
ALL
needed years into the Other Comments box.
Tax Year:
Indicate if you would like your form emailed to the email address on file in the Other Comments Box.
If you wish to have your form mailed, be sure your address includes all components of your mailing address, such as apartment and mailbox numbers.
Mailing Address:
Transportation Subtopic:
Date of Service (Future Event):
Date of Appointment (Past Event):
Broker Name
Please add details about the complaint in the comment box below
Out of State Facility Name:
Address and Phone of Out of State facility:
Appointment Date(s):
Duration of Stay in (other state):
Mode of Transportation:
Referring Provider Contact information:
Client Contact information:
Is the client safe to transport by commercial air?
Does the client need to travel with an escort?
To schedule transportation, please contact the broker in your county.
Click Here
for a list of brokers by county with contact information more information about the NEMT program:
Other Comments:
By selecting this box, you are declaring the information you have provided is either about yourself, or you are authorized to act on behalf of the person whose information you provided.
*
If submitting this form on behalf of someone other than yourself, please provide your name below:
First Name:
Last Name:
Submit Request
Cancel
All responses will be via email.