Ault International Medical Management : New Group Referral

Your Full Name

Email Address

Your Organization

Phone Number

Group Name

Street Address

Zip

Plan Representative Name

Who will be coordinating provision of eligibility files to AIMM?

Contact Name

Group Number

City

Number of Employee Lives

Plan Representative Phone Number

Contact Phone Number

Start Date

State

Grandfathered Status

Plan Representative Email CC on all clinical updates?

Contact Email

TPA

TPA Address

TPA Zip

Phone Number

TPA City

Website

TPA State

Contact Name

Group ID Number

Phone Number

Email Address CC on all clinical updates?

PBM

PBM Address

PBM Zip

Phone Number

PBM City

Website

PBM State

Contact Name

Group ID Number

Phone Number

Email Address CC on all clinical updates?

PPO

Contact Name

Phone Number

Website

Email Address

Reinsurer

Contact Name

Phone Number

Website

Email Address

Consultant/Advisor/Broker Name

Phone Number

Email Address

Does the group have an EPO? Yes No

Is this an RBP plan? Yes No

Will AIMM be performing the Utilization Management (Precertification)? Yes No

New Group Referral

Your Information

Group Demographics

TPA Insurance Information

PBM Insurance Information

PPO Insurance Information

Reinsurer Insurance Information

Consultant/Advisor/Broker Information

EPO Information

Domestic Travel Information

AIMM Services

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