HEALTHCARE PLAN(S) CONTRACT REQUEST MD
Send Contract for SHORT-TERM CARRIER(S) in my state:
National General
UnitedHealthOne (Up to 36 Months of Coverage)
Pivot Health
HII
IHC
Philadelphia American (Scheduled Benefit Plans)
Alternative Health Plan (Permanent HEALTH SHARING PLANS for every need and budget):
Aliera Healthcare
Also send Contracting Information for SPIRIT DENTAL AND VISION:
Spirit Dental and Vision
Full Name as appears on your License
*
First Name
Middle Name
Last Name
Contract Information
E-mail
*
name@youremail.com
Phone Number
*
-
Area Code
Phone Number
License Information
NPN Number
1234567
State of Resident License
List State of Resident License
SUBMIT CARRIER CONTRACT REQUEST(S)
Contact Core Benefits Group with additional information: 901-221-8834
Should be Empty: