App Report
For All Paper & eApps - PLEASE USE ALL CAPS
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Submission Type *
Product Type *
Benefit Advisor *
If you do not see your name, please email support@askhpm.com
Effective Date of App *
Medicare Plan Effective Date
Health Plan *
Please select Carrier from drop down
Name of Plan
ex. "Dividend Prime"
Client's Preferred Language
Client's First Name *
ex. "WILLIAM"
Nickname or Preferred Name
ex. "BILL"
Client's Middle Initial
ex. "M"
Client's Last Name and Suffix *
ex. "DOE" or "DOE" JR. Do not use special characters
Client's Best Phone Number *
(#'s ONLY!) ex. "4079681622"
Client's Secondary Phone Number
(#'s ONLY!) ex. "4079681622"
Client's Best Email
Client's Street Address *
ex. "123 MAIN ST"
Client's Street Address 2
ex. "APT 789"
Client's City *
ex. "ORLANDO"
Client's State *
Please select State
Client's Zip Code *
ex. "32801"
Client's Date of Birth *
MM
/
DD
/
YYYY
Client's MEDICARE BENIFICIARY ID (MBI)
Please enter their MBI Number below
Client's Medicaid ID Number
For Client's with Medicaid please enter their 10 Digit Medicaid ID Number below
Assigned PCP (Primary Care Physician)
ex. "BILL BYRD - Centerwell" Please do not add Dr. or MD
Lead Source *
Please select from the drop down how you acquired your sale.
eApp Confirmation #
Please enter the actual confirmation code ONLY
Existing Member With Assigned PCP? *
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