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The form below should be completed for
AmisysOnline Enrollment.
All other healthcare professionals interested in AmisysOnline are encouraged to call our
number 703-222-0822 or click here to pre-register.
AmisysOnline Basic Subscription - $19.95/month
A Fund is being used to underwrite your basic monthly AmisysOnline subscription fee
for a period of 12 months.
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| Sponsoring Organization: |
| Group/ Name: |
| Group/ Type: |
| PPO HMO Health Plan |
| Group/Department: |
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| HEALTH PLAN
INFORMATION |
| Street Address: |
| Suite/Dept/Etc: |
| City: State: Zip: - |
| Health Plan Telephone: - - |
| Health Plan Facsimile: - - |
| Primary Contact: |
| Title of Primary Contact: |
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| BILLING
INFORMATION Bill to same
address and contact above |
| Business Name: |
| Street Address: |
| Suite/Dept/Etc: |
| City:
State: Zip: - |
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| ADDITIONAL
HEALTH PLAN INFORMATION |
| Number of Memberships: |
| Number of other staff members: |
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| Would you or your staff be interested in learning about
additional Services offered through AmisysOnline? (Check those that apply) |
| Customs reports |
claims processing |
| Interface Third parties software |
Capitation processing |
| Electronic file Transfer/HIAA |
Benefit/Pricing Service |
| Electronic referrals and
eligibility |
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| SUBSCRIBER
INFORMATION |
| Salutation: |
| First Name: |
| Middle Name: |
| Last Name: |
| Suffix: |
| Title (DO, MD, etc.): |
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| Additional Subscriber Information (required
for enrollment processing) |
| Date of Birth: (e.g. mm/dd/yyyy) |
| Gender: Male Female |
| Preferred User ID (must be alphanumeric): |
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