EOB Concierge Enrollment Form for Health Net Members

Employee Name*

Employer Name*

Employee Email*

User Name*

Password:*

Security Question*

Answer*

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.

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EOB Concierge Enrollment Form for Health Net Members

I want to