Agent Intake

CONTRACTING FORMS

AGENT

A to Z AUTOMATION:
1. Email to Agent with links to: MRA, w9, addendum with DD
2. Notification to Matt to LMK when contracts are complete
3 Nancy’s tasks:
a) I am to look in AtoZ for uploaded w9 or I will receive an email with them
b) Need to upload w9 in system
c) Need to add agent to afffiliate site
d) Need to add affiliate to campaign

AGENCY

A to Z AUTOMATION:
1. Email to Agent with links to: MRA, w9, addendum with DD
2. Notification to Matt to LMK when contracts are complete
3 Nancy’s tasks:
a) I am to look in AtoZ for uploaded w9 or I will receive an email with them
b) Need to upload w9 in system
c) Need to add agent to afffiliate site
d) Need to add affiliate to campaign

WHOLESALE

A to Z AUTOMATION:
1. Email to Agent with links to: MRA, w9, addendum with DD
2. Notification to Matt to LMK when contracts are complete
3 Nancy’s tasks:
a) I am to look in AtoZ for uploaded w9 or I will receive an email with them
b) Need to upload w9 in system
c) Need to add agent to afffiliate site
d) Need to add affiliate to campaign

DISCLAIMER:
Your membership is effective upon receipt of membership materials.

This program is NOT insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This program contains a 30-day cancellation period. Member shall receive a reimbursement of all periodic membership fees if membership is cancelled within the first 30 days after the effective date. Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475.

Teladoc: © 2023 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. For dermatology consultations, members must complete a Dermatology Intake Form and upload a minimum of three images through the secure message center before each initial consultation. Teladoc doctors do not issue prescriptions for substances controlled by any federal or state agency or other drugs that may be harmful because of their potential for abuse. Teladoc reserves the right to limit the types of medications that may be prescribed by its network doctors. All prescriptions furnished by a Teladoc doctor are issued in accordance with applicable federal and state law as well as Teladoc policy. In order to still meet your medication needs, Psychiatrists may recommend a medication and can give instructions to your primary care doctor for prescribing a medication for you.

Lab Testing: Lab benefit not available in MD, NJ, NY and RI.

Aetna Dental Disclosure: The discount program provides access to the Aetna Dental Access® network, which is administered by Aetna Life Insurance Company (ALIC). ALIC does not offer or administer the discount program, and is not an affiliate, agent or principal of the discount program. Dental providers are independent contractors and not employees or agents of ALIC. ALIC does not provide dental care or treatment and is not responsible for outcomes.

Teladoc Mental Health Disclosure: Mental Health visits are not available 24/7/365. Mental Health visits will be scheduled. Mental Health visits are not available to minors. All Mental Health specialists may not be available in all states.