PDF
Word
Form 4926 Electronic Funds Transfer Application - Health Insurance Claims Assessment (Hica) - Michigan
What Is Form 4926?
This is a legal form that was released by the Michigan Department of Treasury - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form 4926?
A: Form 4926 is an Electronic Funds Transfer Application for Health Insurance Claims Assessment (HICA) in Michigan.
Q: What is HICA in Michigan?
A: HICA stands for Health Insurance Claims Assessment and it is a program in Michigan that assesses a fee on health insurance claims.
Q: Who needs to fill out Form 4926?
A: Health insurance carriers in Michigan need to fill out Form 4926.
Q: What is the purpose of Form 4926?
A: The purpose of Form 4926 is to apply for participation in the HICA program and to authorize electronic funds transfer for the payment of fees.
Q: Is Form 4926 mandatory?
A: Yes, health insurance carriers in Michigan are required to fill out Form 4926 if they want to participate in the HICA program.
Q: Are there any fees associated with Form 4926?
A: Yes, there are fees associated with the HICA program and these fees are assessed on health insurance claims.
Q: What information is required on Form 4926?
A: Form 4926 requires information such as the health insurance carrier's name, address, contact information, and banking details for electronic funds transfer.
Q: Is there a deadline for submitting Form 4926?
A: Yes, there is a deadline for submitting Form 4926, and it is typically specified by the Michigan Department of Insurance and Financial Services.
Form Details:
- Released on November 1, 2014;
- The latest edition provided by the Michigan Department of Treasury;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form 4926 by clicking the link below or browse more documents and templates provided by the Michigan Department of Treasury.
