Benezon LLC | New Group Request Form

Telemedicine Only?*

No
Yes

Note you have selected only Telemedicine Services. This does not include access to The Benefits App or Advocacy.*

I understand and only want Telemedicine services.

New Client/Group Information

Agency Name

Agency Address

Street City State Zip

New Account Name

New Account Address

Street City State Zip

Agency Information

Name

First Last

Title

Phone

Email

Group/Plan Effective Date

Open Enrollment Date

Telemedicine Go Live Date

(typically the 1st of the month)

Benezon Go Live Date

Flyer Request – Date for Program Promotional & Engagement Flyers

Enter date needed for open enrollment or other meeting date. Please allow up to 5 day turnaround.

Date Notes

Approx. Number EE's

NOTE: Billing is based upon participating census enrollment and is required in advance for all Telemedicine service implementations.

Approx. Number EE Notes

Service Information

Primary Services

Advocacy/Benefits App
Behavioral Health
Telemedicine
Rx

What telemedicine service are you using?*

Benezon
Other

Third-Party Telemedicine Service Name:*

Additional Services

Medical Management Service Notice

We use the above listed Medical Management Service as part of our service offering for this group (separate contracting and implementation directly with the third party medical management service applies). Please have our Benezon service team build this feature into the App and Member Portal for this group.

Choose Medical Management Service

AIMM-Nurse Deb
Other

AIMM-Nurse Deb Phone Number

Please enter a phone number or other indicator (e.g. "Unknown")

Other Service Name

Other Service Phone

Access via the app & integration with the advocacy services?

Yes
No

Product Information

Branding

Please submit a high-resolution logo in JPG or PNG format.

NOTE: We offer three types of billing options as listed below. You will select the appropriate option when submitting the Implementation Form.

Agency Master Bill (Billed at Net Cost – No Billing Fee)
Third Party Billing (TPA, Etc. – Billed at: Net Cost – No Billing Fee)
Direct Group Billing (Billed at Net Cost – plus Direct Billing Fee*)

Direct Billing is a service provided as a convenience to our Clients. There is an administrative fee of $0.25 pepm per each group with a $50.00 cap and a $10.00 minimum. Direct Billing Fees are retained from rates marked up to the Group. In cases where there is no mark up (Groups are billed at Net Cost), Benezon will invoice the agency the Direct Billing Fee.

Special Pricing Instructions and/or Other Information

Comments

This field is for validation purposes and should be left unchanged.