EOB Concierge Enrollment Form for Other Insurance Members

Employee Name*
Member Name*
Employer Name*
Employee Email*
Insurance Carrier*
User Name (case sensitive)*
Password (case sensitive)*
Daytime Phone*
Consent*
I understand
I understand that submitting this form is not a guarantee of coverage. I understand that enrollment in the EOB CONCIERGE PROGRAM is voluntary and I can cancel my participation at any time. By clicking the "Enroll" button below, I authorize eba&m to receive protected health information about me in order to assist me in the filing of my MaxMed105 claims.
Phone
This field is for validation purposes and should be left unchanged.

I want to