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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:
Be sure your address includes all components of your mailing address, such as apartment and mail box 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:
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