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EOB Concierge Enrollment Form
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EOB Concierge Enrollment Form for Other Insurance Members
You must submit a separate form for each member over 18 years of age.
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.
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